Organizing Pneumonia in a Case of cold Agglutinin Disease with Pulmonary Thrombosis

Cold agglutinin disease is a subtype of autoimmune hemolytic anemia that occurs via the activation of specific anti-red blood cell antibodies (agglutinins) at low temperatures. Autoimmune hemolytic anemia has been reported to cause interstitial pneumonia; however, the underlying mechanism remains unclear. We herein report a 46-year-old man diagnosed with cold agglutinin disease complicated by pulmonary thrombosis and organizing pneumonia. Treatment with prednisolone improved the course of cold agglutinin disease and organizing pneumonia in a similar manner. To our knowledge, this is the first report of cold agglutinin associated with organizing pneumonia, suggesting a potential link between the two.

In-depth proteomics reveals the characteristic developmental profiles of early lung adenocarcinoma with epidermal growth factor receptor mutation

INTRODUCTION

Lung adenocarcinoma progresses stepwise from atypical adenomatous hyperplasia to adenocarcinoma in situ (AIS), followed by minimally invasive adenocarcinoma (MIA), and then obvious invasive adenocarcinoma. In this study, we examined the protein expression profiles of early and epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinomas.

METHODS

Fifteen cases of small and EGFR mutation-positive adenocarcinomas were collected, including AIS, MIA, and small invasive adenocarcinoma (SIA). We examined their protein expression profiles by tandem mass tag (TMT)-labeling liquid chromatography-mass spectrometry (LC-MS/MS) and compared the results between AIS and MIA versus SIA. The differentially expressed proteins were then verified by Western blot analysis and immunohistochemistry (IHC). The clinicopathological implications of the proteins were also examined by IHC.

RESULTS

A total of 4220 proteins were identified by LC-MS/MS analysis. Pathway analysis of the differentially expressed proteins revealed that pathways related to interferon α/β signaling, glutamate and glutamine metabolism, and gluconeogenesis were upregulated in SIA relative to AIS. Among the 13 differentially expressed proteins, cellular retinoic acid binding protein 2 (CRABP2), delta(24)-sterol reductase (DHCR24), and adenylate kinase 4 (AK4) were expressed significantly more strongly in SIA than in AIS. Patients with high expression of CRABP2, DHCR24, and AK4 showed a significantly poorer outcome than those with low expression.

CONCLUSION

In comparison with AIS, SIA shows differences in several different protein expression pathways. Furthermore, CRABP2, DHCR24, and AK4 are useful IHC markers for diagnosis of lung adenocarcinoma invasiveness and may be associated with malignant progression of AIS.

Single-cell transcriptomics reveals an angiogenic cell population for therapeutic angiogenesis in adipose tissue

Background

Therapeutic angiogenesis mediated by stem/progenitor cells is an attractive therapeutic option against cardiovascular disease (CVD). Adipose tissue (AT) can be safely obtained even in CVD patients with anti-platelet medications, and it is a readily available source of culture-expanded adipose-derived stem cells (ADSCs) for transplantation. Single-cell transcriptome enables us to screen all the surface markers at once, while conventional strategies have been limited for the number of target markers. Furthermore, gene profiling at single-cell resolution can be used for the quantification of each marker by how many favorable cells can be purified without mixing of detrimental cells.

Purpose

We aimed to identify and characterize a cell population with in vivo angiogenic potential by single-cell RNA sequencing (scRNA-seq) analysis and xenograft experiments.

Methods

We revisited scRNA-seq datasets of single cell fraction from AT, bone-marrow (BM), and umbilical-cord blood (UCB, n=6/organ) to find cell populations with pro-angiogenic potential. Next, we collected AT from CVD patients (n=23) and used multicolor flow cytometry to quantify and sort the specific populations. PBS, the specific marker-negative and unsorted ADSCs were used as controls. Xenograft models of PKH26 pre-labeled human ADSC transplantation in limb ischemia were used to evaluate the lectin capillary density, PKH+ engrafted ADSCs, and blood flow recovery.

Results

Clustering divided CD45–CD31–CD34+ progenitor fraction into 3 clusters. We identified pro-/anti-angiogenic clusters based on the expressions of well-known pro-/anti-angiogenic factors. All genes encoding cell-surface proteins were compared in this functional clustering, resulted in 17 markers screened (Fig. 1A, B). Taken together with enrichment analysis, CD271+ cells showed predominant and pro-angiogenic gene profile from the other top candidates including CD36 and CD54 (Fig. 1C, D). Next, we evaluated the number and gene profile of CD271+ cells in well-known stem cell sources including BM and UCB. Surprisingly, the number of CD271 expressing cells were significantly lower and did not show angiogenic gene profile in BM and UCB (Fig. 2A). In analysis of AT from 23 CVD patients, CD271+ cells were significantly decreased by donor insulin resistance (Fig. 2B). Cell therapy using CD271+ ADSCs demonstrated in vivo angiogenic capacity compared to those of CD271– ADSCs and PBS in limb ischemia model. Furthermore, CD271+ ADSC transplantation showed enhanced efficacy compared to unsorted ADSCs from the same donors (Fig. 2C–E).

Conclusion

In this study, we identified CD271+ cell population in AT as an angiogenic cell population through scRNA-seq analysis and cell therapy experiments. AT obtained from donors without insulin resistance would be the most suitable for CD271+ ADSC isolation. CD271+ ADSC transplantation with a promising angiogenic capacity could contribute better cell-based therapy tackling CVD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science (JSPS) KAKENHI (Tokyo, Japan)

Utility of in vivo zebrafish cardiac assay to predict the functional impact of KCNQ1 variants

Background

Genetic testing for inherited arrhythmias and discriminating pathogenic from benign variants are integral for the gene-based medicine. However, the high throughput in vivo functional analysis for the rare variants of the KCNQ1 potassium channel is scarce.

Purpose

We tested the utility of the in vivo zebrafish cardiac assay for determining the pathogenicity of the KCNQ1 variants identified in patients with long QT syndrome (LQTS) and atrial fibrillation (AF).

Methods

We generated a knock-out zebrafish with CRISPR-mediated insertions or deletions of the KCNQ1 homolog in zebrafish (kcnq1+/+). To test the utility of the cardiac assay, we used five KCNQ1 variants identified in patients with LQTS or familial AF. Human wild-type or mutant KCNQ1 cRNA (Q1) was co-injected with human KCNE1 cRNA (E1) into the F3 generation embryos with homozygous deletions. We dissected the hearts from the thorax at 72 hour-post-fertilization and measured transmembrane potential in zebrafish heart using the disrupted patch technique. Action potential duration was calculated as the time interval between the peak maximum upstroke velocity and 90% of repolarization (APD90). We compared the APD90s with patients' clinical phenotype and IKs density measured by patch-clamp technique in heterologous system.

Results

The mean APD90 of embryos with kcnq1del/del was 279±48 ms, which was restored by injecting Q1 WT and E1 (159±29 ms) to that with kcnq1+/+ (167±28 ms). We tested if the mean APD90 of embryos with kcnq1del/del was restored (shortened) by injecting the KCNQ1 variants. First we tested the dominant negative variant p.S277L and the trafficking deficient variant p.T587M. Patients with these variants showed significant prolonged QT intervals, and patch clamp study showed both variants caused the non-functional channels. Zebrafish cardiac assay showed the mean APD90 of embryos with kcnq1del/del+ Q1 S277L+E1 or Q1 T587M+E1 was significantly longer than that with kcnq1del/del+Q1 WT+E1 (Table). Next we tested in-frame variant c.1472_1473 ins GGACCT, which was identified from a patient with AF and normal QT interval. Patch clamp study showed the current density of the mutant KCNQ1 channel with KCNE1 was comparable to that of wild-type KCNQ1 channel with KCNE1. Zebrafish assay showed the mean APD90 of embryos with kcnq1del/del shortened by injecting Q1 insACCTGG +E1 (Table). Finally we tested a missense variant p.R451Q, which was identified from a patient with LQTS. Patch clamp study showed the currents in the cells transfected with R451Q+KCNE1 were similar to those with WT+KCNE1. Zebrafish assay showed the mean APD90 of embryos with kcnq1del/del+Q1 R451Q+E1 was longer than that with kcnq1del/del+Q1 WT+E1 (Table).

Conclusions

Functional analysis of in vivo zebrafish cardiac assay might be useful for determining the pathogenicity of rare variants in patients with LQTS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Grant-in-Aid for Scientific Research (C)

Progression of liver fibrosis in pulmonary arterial hypertension

Background

Pulmonary arterial hypertension (PAH) causes congestive liver due to right heart failure. There are few cases of PAH that lead to liver cirrhosis, and little attention is paid to liver function in PAH patients. However, it is certain that long-term congestion due to right heart failure in PAH causes a gradual exacerbation of liver dysfunction and affects metabolic function.

Purpose

The purpose of this study is to investigate liver fibrosis associated with the severity and prognosis of PAH.

Methods

This retrospective observational study was included 57 PAH patients and 22 control subjects. PAH patients were assigned to three risk variables according to the simplified risk stratification proposed at the 6thWSPH 2018 after measuring hemodynamic parameters using right heart catheterization, WHO functional class, 6- minutes walking distance (6MWD), and BNP plasma levels. The Fibrosis-4 (FIB4)-index, a liver fibrosis marker, was calculated using the formula: FIB-4 = Age (years) × AST (U/L) / [PLT (109/L) × ALT1/2 (U/L)], and assessed for association with severity of PAH. PAH patients were followed up for 12 years to assess the occurrence of major adverse event, such as death or lung transplantation.

Next, adult 8-week-old C57BL/6 mice were exposed to chronic hypoxia (10% O2) or normoxia for 6 weeks. Then, mice were anesthetized and performed right heart catheterization. Liver tissue was collected for histological assessment by Hematoxylin and eosin and Azan staining, and evaluated RNA expression involved in liver fibrosis by real-time PCR.

Results

The levels of FIB4-index in intermediate and high risk groups of PAH patients had significantly increased compared to those in control group. In PAH patients, FIB4-index was not obviously correlated with hemodynamic parameters, BNP, or 6MWD. Major adverse events occurred in 18 PAH patients (32%): death in 18 (100%) and lung transplant in none (0%). Kaplan-Meier curves for PAH patients with and without major adverse events were constructed based on a cut-off frequency of 2.001 for FIB4-index. During the 12-years follow-up period, major-event-free survival was significantly better in PAH patients with FIB4-index <2.001 than in patients with FIB4-index >2.001 (hazard ratio, 3.3; P=0.038).

In a PAH model mice, hemodynamic parameters showed that chronic hypoxia significantly increased the right ventricular systolic pressure. In histological analysis, there was no significantly difference in liver fibrosis in hypoxia or normoxia group. However, the RNA expression such as αSMA and TGFβ1 associated with liver fibrosis in PAH model mice was increased compared to control mice.

Conclusion

This study showed that the liver fibrosis gradually progressed subsurfacely with severity of PAH. Even the slight liver dysfunction may affect metabolism and cause exacerbation of PAH, so it might be necessary to pay attention to liver fibrosis as one of the risk factors of PAH.

Funding Acknowledgement

Type of funding sources: None.

Different contribution of sympathetic nerve activity to arterial velocity pulse index in hypertensive patients with and without diastolic dysfunction

Introduction

Left ventricular diastolic dysfunction (LVDD) is the main cause of heart failure with preserved ejection fraction (HFpEF). LVDD is related not only to arterial stiffness but also sympathetic nerve activity (SNA). Recent study demonstrated that increased muscle sympathetic nerve activity (MSNA) may be one of contributing factor for arterial stiffness. In clinical practice, Cardio-ankle vascular index (CAVI) provides a reproducible index of arterial stiffness, independent of blood pressure (BP). Recently, Arterial Velocity pulse Index (AVI), which is an index of arterial reflected waves, have been proposed as new index of arterial stiffness. We reported that AVI was associated with MSNA in hypertensive (HT) patients. However, it is still uncertain the effect of LVDD on the association between AVI and SNA in HT patients. Thus, we tested the hypothesis that AVI would be increased and related to MSNA in HT patients with LVDD.

Methods

Patients with essential HT subjects were included in this study. HT was diagnosed as systolic blood pressure (SBP) ≥140mmHg or diastolic blood pressure (DBP) ≥90mmHg. Patients with secondary HT was excluded. AVI was measured from left upper arm by NAS-1000 (Nihon Koden, Japan). CAVI was measured by VaSera VS-1500A (Fukuda Denshi, Japan). Transthoracic echocardiography was performed by trained sonographers. SNA was evaluated by direct recording of MSNA from peroneal nerves.

Results

25 HT patients were included (age 63±14 years, Male/Female 9/16). They were divided into two groups according to E/e' (no LVDD group, E/e' ≤9, N=12; LVDD group, E/e' >9, N=13). There were no significant differences between no LVDD and LVDD groups in age (63±9 vs 69±9 years p=0.205), body mass index (23±3 vs 24±4 p=0.355), BP (SBP 139±16 vs 144±20mmHg p=0.524, DBP 87±15 vs 78±14mmHg p=0.167). LV Ejection Fraction (EF) and Stroke Volume (SV) did not differ between two groups (EF 66±7 vs 69±6% p=0.471, SV 58±7 vs 62±14ml p=0.599). MSNA had tendency to increase in LVDD group compared to no LVDD group (MSNA 53±10 vs 44±12 bursts/100 heartbeats, p=0.052). Contrary to our hypothesis, AVI and CAVI did not differ between two groups (AVI 27±7 vs 29±7 p=0.398, CAVI 8.7±1.4 vs 8.6±1.4 p=0.894). However, a significant correlation was seen between AVI and MSNA in no LVDD group (r=0.57, p<0.05), but no correlation in LVDD group. There is no correlation between CAVI and MSNA in no LVDD and LVDD group. Significant relationship was observed between AVI and CAVI in LVDD group (r=0.61, p<0.05), but no relationship in no LVDD group.

Conclusion

AVI was significantly associated with MSNA in HT patients without LVDD, but not with LVDD. CAVI was related to AVI in HT patients with LVDD, but not without LVDD. MSNA was slightly increased in HT patients with LVDD compared to without LVDD. These results indicate that augmented SNA could contribute to the increase in arterial stiffness in HT patients without LVDD, however, this contribution might be attenuated in HT patients with LVDD.

Funding Acknowledgement

Type of funding sources: None.

Novel variant of the glycerol-3-phosphate dehydrogenase-1 Like (GPD1-L) gene in Japanese Brugada syndrome patients

Background

The incidence of Brugada syndrome (BrS) varies among racial groups. Several studies reported Glycerol-3-Phosphate Dehydrogenase 1-Like (GPD1-L) gene is associated with BrS. However, most of these studies were reported from Western countries, so the evidence about GPD1-L mutation is limited especially among Asian BrS patients. This study aimed to search for rare variants in GPD1-L among Japanese BrS patients and to investigate the pathogenicity.

Method

We performed whole-exome sequencing for patients with Brugada type 1 ECG pattern from Japanese multicenter BrS cohort consisting of SCN5A-negative BrS probands (n=288) and controls (n=372). We conducted patch-clamp study in human embryonic kidney (HEK) 293 cells cotransfected with the wild-type sodium channel (SCN5A) and wild-type or mutant GPD1-L expression plasmid.

Results

We identified a rare variant in GPD1-L, p.D262N (c.784g>a) in 2 of 288 BrS probands, which was not identified in 372 controls. The minor allele frequency of the variant is 0.0014% in the Genome Aggregation Database. One proband was a 49-year-old man and the other was 34-year-old man who both developed a ventricular fibrillation. ECGs of both probands showed Brugada Type 1 pattern after administration of the pilsicainide. In functional study, coexpression of D262N GPD1-L with SCN5A in HEK293 cells significantly reduced inward sodium currents compared with wild-type GPD1-L. Additionally, inward sodium currents with D262N were similar to those with A280V GPD1-L, which was associated with BrS in previous reports (Figure). Also, several pathogenicity prediction programs, such as SIFT (score: 0.031) and PolyPhen2 (score: 0.937) predicted deleterious effects of GPD1-L D262N.

Conclusion

We identified a rare variant in GPD1-L at the rate of 0.7% in Japanese BrS patients without SCN5A mutations. GPD1-L, p.D262N reduces inward sodium currents and may be a novel susceptible variant for BrS in the Japanese population.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Current–voltage curve

Age differences in the association between arterial velocity pulse index and muscle sympathetic nerve activity in hypertensive patients

Background

Increased arterial stiffness characterize by aging. It is reported that age-related increases in muscle sympathetic nerve activity (MSNA) may be one of contributing factor for arterial stiffness. Arterial reflected wave was composed of SNA and aging. Increased arterial reflected wave partly plays an important role in blood pressure. Recently, we reported that arterial velocity pulse index (AVI), a novel index of arterial reflected waves, was associated with MSNA in hypertensive patients. It is still uncertain the effect of age on the association between AVI and SNA in hypertensive patients.

Method

Patients with essential HT and matched non-hypertensive control subjects were included in this study. HT was diagnosed as systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. AVI was measured from left upper arm by NAS-1000. SNA was evaluated by direct recording of muscle sympathetic nerve activity (MSNA) from peroneal nerves.

Results

45 HT patients and 46 control subjects were included. Age, SBP and DBP were significantly increased in HT group compared to control (Age 63±14 vs 42±16 years, p<0.001; SBP 144±16 vs 115±9 mmHg, p<0.001; DBP 80±14 vs 67±9 mmHg, p<0.001). MSNA and AVI were significantly increased in HT group compared to control (MSNA 34±10 vs 25±8 bursts/min, p<0.05; AVI 28±9 vs 17±5, p<0.05). AVI was significantly correlated with MSNA, age, and SBP in HT group. HT group was divided into two groups according to their age (group 1, age ≤63 N=21, group 2, age ≥64 N=26). AVI in group 1 showed correlation with MSNA (r=0.59, p<0.05), but no correlation was seen in group 2. However excluded SBP>160 mmHg subjects in group 2, significant correlation was clarified between AVI and MSNA (r=0.62, p<0.05).

Conclusion

The relationship between AVI and MSNA in HT patients is preserved regardless of aging, however, high blood pressure over 160mmHg might obscure its correlation. These results indicate that AVI is useful to estimate sympathetic nerve activity in high aging HT patient treated <160 blood pressure.

Funding Acknowledgement

Type of funding sources: None.

Early detection of exacerbation of the severe acute respiratory syndrome coronavirus 2 infection using Fitbit (DEXTERITY pilot study)

 

Some patients with coronavirus disease 2019 (COVID-19) experienced sudden death because of sudden symptom deterioration. Thus, an alarm system that could detect early signs of COVID-19 exacerbation beforehand, to prevent serious illness or death of patients while receiving outpatient treatment at home or in hotels is necessary. Here, we tested whether estimated oxygen variations (EOV), a relative physiological scale that represents users' blood oxygen saturation level during sleep measured by Fitbit, predicted COVID-19 symptom exacerbation. Study period was from August to November 2020. We enrolled 23 COVID-19 patients diagnosed by SARS-CoV-2 polymerase chain reaction-positive (mean age ± standard deviation, 50.9±20 years; 70% female), let each patient wore the Fitbit for 30 days; COVID-19 symptoms were exacerbated in 6 (26%). High EOV signal (a patient's oxygen level exhibits significant dip and recovery within the index period) had 80% sensitivity before symptom exacerbations, whereas resting heart rate signal only had 50% sensitivity. Coincidental obstructive sleep apnea syndrome confirmed by polysomnography was detected in a patient by consistently high EOV signals. This pilot study successfully detected early COVID-19 symptoms exacerbation by measuring EOV and may help to identify early signs of COVID-19 exacerbation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The investigational device used in this study, Fitbit Charge 3, was provided by Fitbit Japan. Summary of high EOV signals and eventsThe clinical course of COVID-19

A Case of Pulmonary Metastasis of Breast Cancer 23 Years after Surgery Accompanied with Non-Tuberculous Mycobacterium Infection

Recurrence of oestrogen receptor (ER)-positive breast cancer rarely occurs postoperatively after a long period. Breast cancer cells survive and settle in distant organs in a dormant state, a phenomenon known as "tumour dormancy." Here, we present a 66-year-old woman with recurrence of ER-positive breast cancer in the left lung 23 years after surgery accompanied with non-tuberculous mycobacterium infection (NTM). At the age of 43 years, the patient underwent a right mastectomy and adjuvant hormonotherapy to completely cure breast cancer. Twenty-three years after the operation, when the patient was 66 years old, computed tomography presented nodular shadows in the lower lobes bilaterally with bronchiectasis and ill-defined satellite tree-in-bud nodules. Mycobacterium intracellulare was detected in cultured bronchoalveolar lavage fluid obtained from the left lower lobe by bronchoscopy. Rifampicin, ethambutol, and clarithromycin were started, which resulted in shrinkage of the nodule in the right lower lobe and satellite nodules; however, the nodule in the left lower lobe increased in size gradually. Wedge resection of the left lower lobe containing the nodule by video-assisted thoracoscopic surgery was performed, which demonstrated that the nodule was adenocarcinoma in intraoperative pathological diagnosis; therefore, a left lower lobectomy and mediastinal lymph node dissection were performed. The tumour was revealed to be consistent with recurrence of previous breast cancer according to its morphology and immunohistochemical staining. Furthermore, caseous epithelioid cell granulomas existed in the periphery of the tumour. It is reported that inflammatory cytokines induce reawakening of dormant oestrogen-dependent breast cancer and, in our case, NTM infection might have stimulated the dormant tumour cells in the lower lobe.

A population-based study of outcomes in patients with surgically resected non-small cell lung cancer with anaplastic lymphoma kinase-rearranged mutations: A matched-pair study

The present study aimed to evaluate clinical outcomes in patients with surgically resected non-small cell lung cancer (NSCLC) with anaplastic lymphoma kinase (ALK)-rearranged mutations. A matched-pair analysis in completely resected ALK-rearranged NSLC patients and those with neither ALK nor epidermal growth factor receptor (EGFR) mutations diagnosed at 11 institutes was performed between April 2008 and March 2019. A total of 51 patients with surgically resected ALK-rearranged NSCLC were included. Women constituted 68.6%, and smokers 29.4%. The median age was 65 years. In matched-pair analysis, disease-free survival and overall survival did not differ between patients with ALK-rearranged mutations and those without mutations. Post-recurrence survival in patients with ALK mutations was longer than that of patients with neither ALK nor epidermal growth factor receptor mutations. ALK genetic testing should be performed, even in elderly patients with NSCLC. Favorable prognosis might be expected after appropriate treatment for patients with recurrent ALK-mutated disease.

Recurrence of atrial fibrillation after catheter ablation is associated with major adverse cardiac and cerebrovascular events: insights from AF frontier ablation registry

Background

Recent observational studies have suggested that catheter ablation for atrial fibrillation (AF) is significantly associated with reduced risk for stroke, cardiovascular events and all-cause death. However, little is known whether late recurrence of AF after catheter ablation is associated with worse clinical outcomes.

Purpose

We aimed to clarify whether late recurrence of AF after catheter ablation is associated with major adverse cardiac and cerebrovascular events (MACCE).

Methods

We retrospectively investigated 2,737 participants (74.4% men, mean age 63.4±10.3 years, 62.7% paroxysmal AF) who received first catheter ablation for AF and completed follow-up more than 3 months after the procedure from AF Frontier Ablation Registry, a multicenter cohort study in Japan. We evaluated an association between late recurrence of AF after catheter ablation and first MACCE in cox-regression hazard models adjusted for known risk factors. MACCE were defined as stroke/transient ischemic attack (TIA), cardiovascular events or all-cause death. Late recurrence was defined as AF relapse more than 3 months after the procedure.

Results

During a mean follow-up period of 25.2 months, 2,070 patients (75.6%) were free from AF after catheter ablation and 122 patients (4.5%) had MACCE (ischemic stroke 18 [14.8%], hemorrhagic stroke 16 [13.1%], TIA 7 [5.7%], hospitalization for heart failure 19 [15.6%], acute coronary syndrome 19 [15.6%], hospitalization for other cardiovascular events 24 [20%] and all-cause death 19 [15.6%]). The MACCE occurred significantly more frequently in the recurrence group than in non-recurrence group (7.5% vs. 3.5%; hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.28–2.65; P=0.001) (Figure). Multivariate analysis revealed that baseline age (HR 1.05; 95% CI 1.03–1.08; P<0.001), heart failure (HR 1.76; 95% CI 1.17–2.66; P=0.007), old myocardial infarction (HR 4.49; 95% CI 2.59–7.81; P<0.001), non-ischemic cardiomyopathy (HR 2.56; 95% CI 1.47–4.46; P=0.001), left atrial diameter (HR 1.22 per 5-mm increase; 95% CI, 1.06–1.41; P=0.006) and recurrence of AF (HR 1.69; 95% CI 1.17–2.44; P=0.005) were independently associated with the incidence of MACCE after catheter ablation.

Conclusion

In the Japanese multicenter cohort of AF ablation, late recurrence of AF was independently associated with increased MACCE, suggesting the significance of sinus rhythm maintenance by catheter ablation.

Kaplan-Meier curves for MACCE

Funding Acknowledgement

Type of funding source: None

Nerve growth factor receptor is involved in maintaining homeostasis of pulmonary arterial hypertension

Introduction

Pulmonary arterial hypertension (PAH), characterized by vascular remodeling, is still disease with poor prognosis although many pulmonary vasodilators have been developed, and new mechanism of treatment for PAH is desired. Nerve growth factor receptor (Ngfr) is known to relate to inflammatory reaction and repair process in the damaged tissue. We have reported that Ngfr is associated to vascular remodeling in patients with acute coronary syndrome. However, it is unclear how Ngfr is involved in the pathogenesis of PAH.

Purpose

In this study, we investigated whether Ngfr relate to pathophysiology in PAH.

Methods

We estimated the frequency of Ngfr positive cells (% Ngfr+) in peripheral blood mononuclear cells obtained from PAH and non-PAH patients using flowcytometric analysis. In PAH patients, the hemodynamic parameters such as mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were obtained by right heart catheterization, and evaluated for correlation with the % Ngfr+.

Next, adult 8-week-old C57BL/6 (WT) mice and Ngfr knock out (KO) mice were exposed to chronic hypoxia (10% O2) or normoxia for 6 weeks. Then, mice were anesthetized and performed echocardiography and right heart catheterization. Then, mice were exsanguinated and blood sample was collected to evaluate the % Ngfr+ by flow cytometry. Right ventricular weight was measured and lung tissue was also collected for histological assessment and molecular pathway profiling.

Results

PAH (n=24) patients and non-PAH patients (n=17) were enrolled. The % Ngfr+ was significantly higher in PAH patients than that in non-PAH patients (0.056% versus 0.019%, p<0.0001). In PAH patients, the % Ngfr+ was correlated with severity of hemodynamic parameters such as mPAP (R=0.64 p<0.001), PVR (R=0.62 p<0.005), and CI (R=−0.48 p<0.05).

In WT mice, chronic hypoxia significantly increased the right ventricular systolic pressure and induced vascular medial thickness and fibrosis around the pulmonary artery. Flow cytometry analysis revealed that the % Ngfr+ was significantly increased in the hypoxia compared to that in the normoxia. Under hypoxic conditions, the right ventricular systolic pressure was significantly increased in Ngfr KO mice compared to that in WT mice. In histological analysis, hypoxia-induced peripheral vascular fibrosis and medial thickness was more severe in Ngfr KO than that in WT mice.

Conclusion

Circulating Ngfr-positive cells are associated with severity of PAH in patients. In the hypoxia-induced PH model, gene deletion of Ngfr shows the progression of the pathogenesis of PAH. These results suggest that circulating Ngfr-positive cells have an important role in the pathogenesis of PAH and may be a novel target for PAH therapy.

Funding Acknowledgement

Type of funding source: None

Novel index of arterial reflected waves, Arterial Velocity pulse Index, relates to muscle sympathetic nerve activity independent of Arterial Pressure volume Index in patients with hypertension

Background

Arterial reflected wave is determined by not only atherosclerosis but also sympathetic nerve activity. Recently, Arterial Velocity pulse Index (AVI), which is an index of arterial reflected waves, and Arterial Pressure volume Index (API), which is an index of volume of a conductive blood vessel, have been proposed as new index of arterial stiffness. However, it is unclear whether API and AVI would be associated with muscle sympathetic nerve activity (MSNA) in hypertensive subjects.

Purpose

The purpose of this study was to evaluate the correlation between AVI, API and MSNA in hypertensive subjects.

Method

41 hypertensive patients and 40 non-hypertensive subjects were included in this study. We performed a cross-sectional, observational study. Hypertension (HT) was defined as systolic blood pressure (SBP) ≥140 mmHg, diastolic blood pressure (DBP) ≥90 mmHg or medical treatment for HT. AVI and API was measured by NAS-1000 (Nihon Koden, Japan). MSNA, central sympathetic outflow to peripheral muscle, was recorded directly from peroneal nerve. MSNA was expressed by burst frequency (bursts/minute) and burst incidence (bursts/100heartbeats). Blood pressure, heart rate and MSNA were recorded simultaneously.

Results

Age, systolic and diastolic pressure were significantly higher in hypertensive patients compared to control (40±15 vs 61±13 years, p<0.001; 142±16 vs 113±9 mmHg, p<0.001; 81±14 vs 67±9 mmHg, p<0.001). MSNA and AVI were significantly augmented in hypertensive patients compared to control (34±11 vs. 23±6 bursts/min, p<0.05; 26±7 vs. 16±4, p<0.05). AVI was correlated with MSNA in each group (hypertension: r=0.59, P<0.001, non-hypertension: r=0.51, p<0.001). However, no correlation was shown between API and MSNA in each group (hypertension: r=0.22, p=0.15, non-hypertension: r=0.07, p=0.63). Multiple regression analysis also showed MSNA was significantly related with AVI but was not with API.

Conclusion

Our finding showed that AVI relates to MSNA independent of API in patients with hypertension. It suggested that Novel index of arterial reflected waves, AVI, is helpful to estimate augmented SNA in hypertensive subjects regardless of volume of a conductive blood vessel.

Funding Acknowledgement

Type of funding source: None

Rare SCN10A variants associated with cardiac conduction system diseases

Background

The genetic bases of cardiac conduction-system disease (CCSD) range from ion channelopathies to mutations in many other genes. Genome-wide association studies have shown common variants in SCN10A influence cardiac conduction. However, it has not yet to be determined whether vulnerability to CCSD is associated with rare coding sequence variation in the SCN10A gene.

Purpose

We sought to determine the clinical impact of rare variants in SCN10A in patients with CCSD and classified the variants according to the 2015 American College of Medical Genetics and Genomics (ACMG) standards and guidelines.

Methods

We performed screening for rare variants (minor allele frequency ≤0.001) in SCN10A in CCSD patients with an onset at a young age under 65 or those who had a family history of pacemaker implantation (PMI) (n=40; 18 female; mean age, 41±18 years). We transiently expressed engineered variants in ND 7/23 cells, and conducted whole-cell voltage clamp experiments to clarify the functional properties of the Nav1.8 current.

Results

We identified nine rare variants in SCN10A in 7 patients. Two patients were carriers of two rare variants in SCN10A and 5 were carriers of one rare variant in SCN10A. Four patients were affected with sinus node dysfunction, 1 were atrioventricular block, and 2 were both dysfunctions. We performed electrophysiological study for 8 of 9 rare variants. It demonstrated that 2 rare variants showed gain-of-function, and 3 rare variants showed loss-of-function. We finally determined 5 likely pathogenic variants in SCN10A in 5 patients (12.5%) according to the ACMG standards and guidelines. All 5 patients underwent a pacemaker implantation at an average age of 43±16.

Conclusions

These results demonstrate that SCN10A variants play a pivotal role in enhanced susceptibility of CCSD. We suggest the importance for screening SCN10A variants in clinical settings.

Funding Acknowledgement

Type of funding source: None

Bone marrow-derived NGFR+ cells regulate arterial remodeling and those poor mobilizations in peripheral blood in acute coronary syndrome predicts plaque progression at the non-targeted lesion

Background

In our previous 5-year cohort study, we demonstrated that low gene expression of nerve growth factor receptor (NGFR) in peripheral leucocytes in acute coronary syndrome (ACS) predicted repetitive coronary interventions at the de novo lesions. An NGFR-positive cell has been demonstrated to reside in bone marrow (BM) stromal fraction and to be increased in peripheral blood mononuclear cell (MNCs) fraction in patients with ischemic heart disease.

Purpose

To investigate whether the BM-NGFR+ cell is associated with arterial remodeling and the relationship between the levels of peripheral NGFR+ cells after ACS and coronary plaque progression in an experimental and prospective clinical study.

Methods and results

In an experimental study, 8-week-old C57B6/J wild type male mice were subjected to irradiation with 9.6 Gy and transplantation with BM (BMT) isolated from GFP-transgenic NGFR wild type (WT) or knock-out (KO) mice at day 1. Four weeks after BMT, the right carotid artery was ligated for 4 weeks. Induced neointimal area was increased (p<0.05), where cells under apoptosis were decreased (p<0.05) in NGFR-KO-BMT group compared to WT-BMT group (n=4). NGFR+ cells were not detected in wild type sham-operated artery, whereas in the ligated artery in WT-BMT group NGFR+ cells assembled in the developed neointima and exclusively presented double positive with GFP, but absent in NGFR-KO-BMT group (p<0.05, n=4). In a clinical study, thirty patients with ACS who underwent primary percutaneous coronary intervention (PCI) were enrolled. The peripheral blood sample was collected on days 0, 3 and 7, and 9 months follow-up and the number of NGFR+MNCs were measured by flowcytometric analysis. The plaque volume at non-targeted coronary lesion (non-TL:>5 mm proximal or distal to the implanted stents) were quantitatively analysed using gray-scale intravascular ultrasound (IVUS) and Q-IVUS™ software at the acute phase and 9 months follow-up. The number of NGFR+MNCs in peripheral blood was 1.5-fold increased at day 3 (0.064±0.056%) compared to day 0 (0.042±0.030%) (p<0.05). The change in normalized total plaque volume (TAVN) at non-TL at 9 months was negatively correlated with the number of NGFR+MNCs at day 0 (r=−0.51), day 3 (r=−0.51) and 9 months (r=−0.59) after ACS (p<0.05). Multiple regression analysis showed that NGFR+MNCs at day 0 (β=−0.48, p=0.01) and CRP (β=−0.53, P<0.01) are independent factors associating with TAVN change at non-TL at 9 months, regardless of LDL-cholesterol control level. ROC analysis revealed that NGFR+MNCs <0.049 at day 0 predicted the increase of TAVN with AUC 0.78; sensitivity 0.82 and specificity 0.67.

Conclusions

Bone marrow-derived peripheral NGFR+ cells negatively regulate arterial remodeling through appropriate apoptosis of neointimal cells and the peripheral level of NGFR+ cells in ACS predicts plaque progression at the non-targeted lesion.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): KAKENHI

CLIF-C Organ Failure Score and Liver Volume Predict Prognosis in Steroid-Treated Severe Acute Autoimmune Hepatitis

Controversies and debates remain regarding the best management of severe acute‐onset autoimmune hepatitis (SA‐AIH) due to the lack of useful outcome or complication prediction systems. We conducted this clinical practice‐based observational study to clarify whether Chronic Liver Failure Consortium Organ Failure scores (CLIF‐C OFs) and the computed tomography–derived liver volume to standard liver volume (CTLV/SLV) ratio at admission to a tertiary transplant center can predict outcomes and complications due to infection. Thirty‐four consecutive corticosteroid‐treated patients with SA‐AIH from 2007 to 2018 were included. Severe hepatitis was defined as an international normalized ratio (of prothrombin time) over 1.3 any time before admission. Of the 34 corticosteroid‐treated patients with SA‐AIH inclusive of 25 (73.5%) acute liver failure cases, transplant‐free survival was observed in 24 patients (70.6%). Any infection was noticed in 10 patients (29.4%). CLIF‐C OFs, at the cutoff of 9, significantly predicted survival (P = 0.0002, log‐rank test), outperformed the Model for End‐stage Liver Disease system in predicting outcome (P = 0.0325), and significantly discriminated between liver transplant and death in a competing risk analysis. SA‐AIH was characterized as having decreased CTLV/SLV, which was also predictive of survival (P < 0.0001). Interestingly, CLIF‐C OFs, especially the subscores for respiratory dysfunction, also predicted infection (P = 0.007). Conclusion: In corticosteroid‐treated patients with SA‐AIH, CLIF‐C OFs and CTLV/SLV ratios predicted both survival outcome and complications due to infection. Further investigation is warranted to determine whether making decisions based on CLIF‐C OFs or CTLV/SLV ratios is useful.

A case of Marfan syndrome with massive haemoptysis from collaterals of the lateral thoracic artery

BACKGROUND

Marfan Syndrome (MFS) is a heritable connective tissue disorder with a high degree of clinical variability including respiratory diseases; a rare case of MFS with massive intrathoracic bleeding has been reported recently.

CASE PRESENTATION

A 32-year-old man who had been diagnosed with MFS underwent a Bentall operation with artificial valve replacement for aortic dissection and regurgitation of an aortic valve in 2012. Warfarin was started postoperatively, and the dosage was gradually increased until 2017, when the patient was transported to our hospital due to sudden massive haemoptysis. Computed tomography (CT) with a maximum intensity projection (MIP) revealed several giant pulmonary cysts with fluid levels in the apex of the right lung with an abnormal vessel from the right subclavian artery. Transcatheter arterial embolization was performed with angiography and haemostasis was achieved, which suggested that the bleeding vessel was the lateral thoracic artery (LTA) branch. CT taken before the incident indicated thickening of the cystic wall adjacent to the thorax; therefore, it was postulated that the bleeding originated from fragile anastomoses between the LTA and pulmonary or bronchial arteries. It appears that the vessels exhibited inflammation that began postoperatively, which extended to the cysts.

CONCLUSION

We experienced a case of MFS with massive haemoptysis from the right LTA. We have to be aware of the possibility that massive haemoptysis could be induced in MFS with inflamed pulmonary cysts.

P2850Time to isolation guided hot balloon ablation for pulmonary vein isolation

Background

One disadvantage of hot balloon ablation (HBA) system is that real time monitoring of pulmonary vein (PV) potential is technically impossible. Therefore, the optimal radiofrequency-generated thermal energy application duration and application number are not completely established.

Purpose

The aim of this study is to evaluate the utility of 2Fr 4-electrode unidirectional catheter inserted into PV along with HB for real time monitoring of PV potential and investigate the time to isolation (TTI) guided optimal application strategy for HB based PV isolation in the acute phase.

Methods

We evaluated 23 consecutive patients who performed PV isolation using HBA system. Real time monitoring of PV potential was performed by 2Fr 4-electrode unidirectional catheter inserted into PV along with HB (Figure1A). After HBA applications, PV isolation was validated by high-resolution mapping with the 20-pole steerable mapping (PENTARAY) catheter as a standard. PV potentials during HBA application were categorized into five patterns. PV potentials disappeared during HBA applications and not emerged again (acute isolation), disappeared but verified by PENTARAY catheter (pseudo isolation), once disappeared but emerged again during the same application (acute reconnection), visible but not disappeared (ineffective application) and Invisible (Figure1B).

TTI, difference between TTI and time to reach target temperature (TTRT), balloon temperature at isolation and ablation time after isolation were examined for each applications.

Results

Out of 92 PVs, 69/92 (75.0%) PVs were isolated using HBA and 23/92 (25.0%) PVs required touch up ablation. In total, 120 applications were performed. Real time monitoring of the PV activity was obtained in 114 of 120 applications (95.0%). The distribution of PV potential patterns were 64/120 (53.3%), 2/120 (1.7%), 27/120 (22.5%), 23/120 (19.2%), for acute isolation, pseudo isolation, acute reconnection, ineffective application, respectively.

TTI and difference between TTI and TTRT were significantly shorter in the acute isolation group. Balloon temperature at isolation was significantly lower, TTRT and ablation time after isolation was significantly longer in the acute isolation group. Among them, TTI and difference between TTI and TTRT were highly predictive by receiver operation characteristics curve analysis. TTI <36.5s predicted successful application with sensitivity 83.9% and specificity 79.3%. Difference between TTI and TTRT <6.5s predicted with sensitivity 82.3% and specificity 89.7%.

Figure 1

Conclusions

In HBA system, real time monitoring of PV potentials can be obtained using 2Fr 4-electrode unidirectional catheter and accuracy to confirm an ostial PV isolation is relatively high.

TTI <36.5s and difference between TTI and TTRT <6.5s could be a suitable target for effective application.

1417Effect of sodium glucose cotransporter 2 inhibitor on sympathetic nerve activity in type 2 diabetes mellitus patients

Background

Diabetes mellitus (DM) is a well-known risk factor for cardiovascular diseases. Augmented sympathetic nerve activity plays an important role in the progressive worsening disease severity. Most of anti-diabetic drugs were demonstrated to not only decrease blood glucose, but also increase sympathetic nerve activity. Recently, it has been reported that sodium glucose cotransporter 2 (SGLT2) inhibitor has beneficial effects on cardiovascular events in spite of the decrease in blood glucose in type 2 DM patients. The underlying mechanisms remain speculative; however, it is assumed that SGLT2 inhibitor would improve sympathetic nerve activity in type 2 DM patients.

Purpose

The purpose of this study was to evaluate the effect of SGLT2 inhibitor on sympathetic nerve activity in type 2 DM patients.

Methods

This study was designed as the prospective single-arm study. Type2 DM patients whose HbA1c >7.0% with at least one atherosclerotic risk factors (Hypertension, obesity, smoking history, aging ...) were included. Patients who had renal failure (eGFR<45ml/min/1.73m2) or high age patients (>80 years old) were excluded. We measured blood glucose, HbA1c and blood insulin concentration at baseline and 12 weeks after treatment of dapagliflozin (5mg/day). Muscle sympathetic nerve activity (MSNA) was applied to scrutinize accurate sympathetic nerve activity in type 2 DM patients. Also, baroreflex sensitivity was calculated by examining the relationship between MSNA and beat to beat diastolic blood pressure.

Results

Eleven type2 DM patients were included in this study. Body mass index, blood pressure, HbA1c and blood insulin concentration tended to decrease at 12weeks after dapagliflozin (body mass index: 27.2±6.3 vs. 24.9±3.2 kg/m2. systolic blood pressure: 121±12.3 vs. 118±13.6 mmHg. diastolic blood pressure: 74.3±6.3 vs. 72.5±7.6 mmHg. HbA1c: 7.6±0.3 vs. 7.2±0.7%. insulin: 9.7±7.2 vs. 8.8±5.1 μU/ml). Dapagliflozin significantly decrease MSNA and heart rate compared to baseline (46.7±7.5 vs. 38.6±6.9 bursts/minute, P<0.05. Heart rate: 80.6±8.5 vs. 72.8±7.4 beats per minute, P<0.05). However, there is no interaction between the reduction in MSNA and baroreflex sensitivity or insulin resistance.

12 weeks administration decreased MSNA

Conclusion

Our data demonstrated that dapagliflozin significantly decreased MSNA and HR beyond the lowering effect of blood glucose in type2 DM patients. These results indicate the favorable effect of SGLT2 inhibitor might be, in part, attributed to the improvement in sympathetic nerve activity.

P3495Long-term engraftment of human CD271-positive adipose-derived stem cells with pericytic and less-aged gene profile in a mouse model of hindlimb ischemia

Background

Therapeutic angiogenesis using adipose-derived stem cells (ADSCs) is an attractive strategy for ischemic cardiovascular diseases. We previously reported that human CD271+ population of adipose-derived stem cells (ADSCs) promoted neovascularization with enhanced engraftment in a mouse model of hindlimb ischemia. However, whether and how CD271+ ADSCs promote the long-term engraftment is still uncertain.

Purpose

We aimed to examine whether the angiogenic effect and cell engraftment capacity of CD271+ ADSCs would be sustained in long-term period. Then, comparative gene profiling between CD271+ and CD271- ADSCs were analyzed. Finally, cell proliferation and endothelial differentiation assays were conducted.

Methods

ADSCs were isolated from subcutaneous adipose tissue of 5 patients received cardiovascular surgery. CD271+ and CD271- ADSCs were sorted from CD45-CD31-CD34+ ADSCs fraction by FACS sorting (Fig. A). Cultured CD271+ and CD271- ADSCs at passage 6 were labeled by PKH26 cell linker dye and used for xenograft experiments. Briefly, athymic nude mice were subjected to hindlimb ischemia and one million of human ADSCs were injected into the ischemic muscles. In control group, PBS was solely injected. At 2 and 5 weeks, neovascularization was evaluated by immunohistochemistry (capillary density using lectin perfusion). Cell engraftment was assessed by counting PKH26-positive cells. Furthermore, we compared gene profiling between CD271+ and CD271- ADSCs by microarray. Proliferative capacity was evaluated by colony-forming unit (CFU) assay with Giemsa staining. In endothelial differentiation assay, CD271+ and CD271- ADSCs were cultured in differentiation induction medium containing vascular endothelial growth factor for 2 weeks and stained with anti-human CD31 antibody.

Results

Cell therapy using CD271+ ADSCs demonstrated approximately 3-fold more enhanced neovascularization than those using CD271- ADSCs or PBS in histological analysis of capillary density at 2 weeks from cell therapy (Fig. B and C). At 5 weeks, mice treated with CD271+ ADSCs were significantly rescued from limb ischemia and this was accompanied by sustained engraftment of ADSCs (Fig. D). In microarray analysis, the differentially expressed 2167 genes were extracted to classify CD271+ and CD271- ADSCs. Pathway analysis demonstrated CD271 expression on ADSCs was associated with the pathways related to stemness and cell differentiation. Indeed, we found that genes related to cell proliferation (PI3K, Cyclin D, and Cyclin D2) were up-regulated in CD271+ ADSCs. Additionally, we found the pericytic marker nestin which was significantly up-regulated in CD271+ ADSCs. Consistent with these findings, CD271+ ADSCs were more proliferative and capable for endothelial differentiation while CD271- ADSCs were not.

FACS and cell therapy experiments

Conclusion

These results suggest that CD271+ ADSCs possess long-term engraftment and angiogenic capacity due to their less-aged and more pericytic gene profile.

Acknowledgement/Funding

Japan Society for the Promotion of Science (JSPS) KAKENHI (Tokyo, Japan) Grant Number JP16H06828

P2590A liver-derived secretory protein, selenoprotein P causes pressure overload-induced cardiac hypertrophys

Background

Hepatokine selenoprotein P (SeP) contributes to insulin resistance and hyperglycemia in patients with type 2 diabetes. Inhibition of SeP protects the heart from ischemia reperfusion injury and serum levels of SeP are elevated in patients with heart failure with reduced ejection fraction.

Objective

We investigated the role of SeP in the regulation of cardiac remodeling in response to pressure overload.

Methods and results

To examine the role of SeP in cardiac remodeling, transverse aortic constriction (TAC) was subjected to SeP knockout (KO) and wild-type (WT) mice for 2 weeks. Hepatic expression of SeP in WT was significantly increased by TAC. LV weight/tibial length (TL) was significantly smaller in SeP KO mice than in WT mice (6.75±0.24 vs 8.33±0.32, p<0.01). Lung weight/TL was significantly smaller in SeP KO than in WT mice (10.46±0.44 vs 16.38±1.12, p<0.05). TAC-induced cardiac upregulation of the fetal type genes, including atrial and brain natriuretic factors, was significantly attenuated in SeP KO compared to WT. Furthermore, azan staining revealed that there was significantly less interstitial fibrosis in hearts after TAC in SeP KO than in WT mice. To determine whether hepatic overexpression of SeP affects TAC-induced cardiac hypertrophy, a hydrodynamic injection method was used to generate mice that overexpress SeP mRNA in the liver. Hepatic overexpression of SeP in SeP KO mice lead to a significant increase in LV weight/TL and Lung weight/TL after TAC compared to that in other SeP KO mice.

Conclusions

These results suggest that cardiac pressure overload induced hepatic expression of SeP and the absence of endogenous SeP attenuated cardiac hypertrophy, dysfunction and fibrosis in response to pressure overload in mice. SeP possibly plays a maladaptive role against progression of heart failure through the liver-heart axis.

P1580Left atrial volume index predicts improvement in renal function after catheter ablation of atrial fibrillation

Background

Atrial fibrillation (AF) increased the risk of development of kidney disease. The elimination of AF by catheter ablation is associated with improvement in renal function. However, the mechanism of cardio-renal interaction in AF has not been fully elucidated.

Purpose

We tested the hypothesis that left atrial volume index (LAVI), which is a marker of left atrial mechanical reserve, predicts improvement in renal function after restoring sinus rhythm with catheter ablation of AF.

Methods

We analyzed consecutive patients who underwent catheter ablation of AF from January 2012 to October 2018 and had completed follow-up more than 3 months after catheter ablation. Exclusion criteria were need for hemodialysis and acute hospitalization. Estimated glomerular filtration rate (eGFR) was assessed on admission and at the end of follow-up periods after catheter ablation and the difference was defined as ΔeGFR. Left atrial volume index was derived using the biplane area-length method.

Results

A total of 159 AF patients (paroxysmal 112 [70%], persistent 47 [30%]) were included in this study. The mean age was 65±11 years and 74% were male. During the mean follow-up period of 7.9±3.2 months, 105 patients (66%) were free from atrial tachyarrhythmias and 54 (34%) experienced the recurrence. Baseline eGFR and LAVI were not significantly different between the non-recurrence group and the recurrence group (71.0±17.4 and 75.1±22.8 mL/min/1.73m2; p=0.24, 35.7±12.5 and 37.9±15.0 ml/m2; p=0.34). ΔeGFR in the non-recurrence group was significantly greater compared with the recurrence group (+1.5±1.0 versus −4.3±1.4 mL/min/1.73m2; p=0.001). Baseline LAVI was negatively correlated with ΔeGFR in the non-recurrence group (r=−0.3; p=0.002; Figure), but not in the recurrence group (p=0.1). Multiple regression analysis in the non-recurrence group identified baseline LAVI (β=−0.35, p<0.001), baseline age (β=−0.31, p<0.001) and baseline eGFR (β=−0.59, p<0.001) as independent predictors for eGFR improvement after catheter ablation. In the patients with LAVI <34 ml/m2, age <70 years and eGFR <90 mL/min/1.73m2, the mean ΔeGFR was +6.3±1.9 mL/min/1.73m2.

Figure 1

Conclusions

LAVI, a marker of left atrial mechanical reserve, was an independent predictor of improvement in renal function after restoring sinus rhythm with catheter ablation of AF. This observation suggests that AF-related deterioration of renal function is due at least in part to impaired atrial mechanical function.

Liver Fibrosis Markers Improve Prediction of Outcome in Non-Acetaminophen-Associated Acute Liver Failure

A prognostic system for acute liver failure (ALF) with a higher predictive value is urgently needed. The role of extracellular matrix (ECM) remodeling in ALF has not been fully elucidated. We hypothesized that serologic fibrosis markers, which reflect ECM remodeling, are predictive of ALF outcome at first presentation. This observational study included 110 patients with acute liver dysfunction, of which 73 had non-acetaminophen-associated ALF (NAA-ALF). We evaluated serum levels of hyaluronic acid, 7S domain of type IV collagen (4COL7S), and Wisteria floribunda agglutinin-positive Mac-2-binding protein at first presentation to a tertiary center. Serologic fibrosis markers were significantly higher in NAA-ALF compared with acute hepatitis. Elevated hyaluronic acid and 4COL7S levels at first presentation correlated significantly with worse clinical outcomes. 4COL7S, along with age, ammonia, and the Model for End-Stage Liver Disease (MELD) score, was a significant prognostic factor in multivariate analysis; 4COL7S correlated significantly with coagulopathy, decreased hepatic synthetic functions, advanced hepatic encephalopathy, and liver atrophy and also predicted 180-day transplant-free survival. Cox regression models incorporating 4COL7S with the MELD system had profoundly improved predictive values that significantly surpassed the MELD system alone. Conclusion: Elevation of serologic fibrosis markers reflecting ECM remodeling in NAA-ALF predicted a worse clinical outcome. Incorporation of 4COL7S at first presentation to a transplant center improves the specificity while retaining the sensitivity of the MELD system. External validation of a fibrosis marker as part of a clinical prediction tool in ALF warrants further investigation.

Detection of bacterial DNA by in situ hybridization in patients with decompensated liver cirrhosis

Background

Spontaneous bacterial peritonitis (SBP) is often difficult to diagnose because bacteria in ascites cannot be detected accurately by conventional culture. In situ hybridization (ISH) was previously developed for rapid detection of genes from bacteria phagocytized by neutrophils. SBP may develop after bacteria enter into the systemic circulation following bacterial translocation. Therefore, we performed ISH to identify bacteria in blood samples collected from patients with decompensated liver cirrhosis (LC).

Methods

In this retrospective study, peripheral blood samples were collected from 60 patients with decompensated LC, and bacteria were detected by both blood culture and ISH. Moreover, 35 patients underwent paracentesis for diagnosis of SBP.

Results

Eight of 35 patients were diagnosed with SBP by polymorphonuclear neutrophil counts, and one patient was diagnosed with bacterascites. Seven of the nine patients showed positive results for ISH, whereas bacteria were detected in only two cases by blood culture. Thirty-seven of 60 cases (62%) showed positive results for ISH, whereas only six samples (10%) were positive by blood culture analysis. Compared with the 23 cases of negative ISH, the 37 cases of positive ISH showed a higher frequency of fever, higher Child-Pugh scores, and lower albumin levels.

Conclusions

Detection of bacteria by ISH suggested that bacterial translocation, which cannot be proven by conventional culture, occurred in these patients, and that ISH could be helpful for the early diagnosis of some types of infection and prevention of SBP in these patients.

[CLINICAL UTILITY OF T-SPOT.TB ASSAY WITH T-Cell Xtend REAGENT FOR ACTIVE TUBERCULOSIS DIAGNOSIS IN THE FIELD TEST AT OUR HOSPITAL]

BACKGROUND

T-SPOT.TB (T-SPOT), an interferon-gamma release assay, has shown promise as a diagnostic tool for active tuberculosis (TB), and its use is expanding. Addition of the T-Cell Xtend (TCX) reagent may allow delayed processing, and this characteristic is important for using this test in the field. However, limited data is available on the usefulness of T-SPOT with TCX as a field test for diagnosing active TB.

PURPOSE

To investigate the clinical utility of T-SPOT with TCX and the risk factors for a false-negative result in patients with active TB.

METHODS

A total of 57 patients with active TB who underwent the T-SPOT test with TCX prior to treatment were enrolled between May 2013 and May 2015. One patient with an indeterminate result for T-SPOT was excluded; therefore, the data of 56 patients were eventually included in the final analysis. The basic characteristics and clinical findings were compared between the true-positive and false-negative T-SPOT groups.

RESULTS

Of the 56 patients, 40 (71.4%), 13 (23.2%), 3 (5.4%) had true-positive, false-negative, and borderline T-SPOT results, respectively. This study did not reveal any significant risk factors for a false-negative T-SPOT result.

CONCLUSION

In this clinical study, the proportion of patients with a false-negative result for T-SPOT with TCX for active TB was higher than that reported previously. Therefore, careful interpretation of a negative result for T-SPOT with TCX is necessary, regardless of the patient's background.

Low-load Slow Movement Squat Training Increases Muscle Size and Strength but Not Power

We tested a hypothesis that low-load squat training with slow movement and tonic force generation (LST) would increase muscle size and strength but not necessarily power. Healthy young men were assigned to LST [50% one-repetition maximum (1-RM) load, 3 s for lowering/lifting without pause: n=9] or low-load normal speed (LN: 50% 1-RM load, 1 s for lowering/lifting with 1-s pause; n=7) groups. Both groups underwent an 8-week squat training program (10 repetitions/set, 3 sets/day, and 3 days/week) using the assigned methods. Before and after the intervention, quadriceps femoris muscle thickness, maximal torque during isometric hip extension and knee extension, 1-RM squat, lifting power from squatting position and rate of electromyography rise (RER) in knee extensors during the task, leg extension power and vertical jump height were measured. After the intervention, the LN group showed no changes in all the variables. The LST group significantly (P<0.05) increased muscle thickness (6-10%), isometric hip extension torque (18%) and 1-RM squat (10%), but not isometric knee extension torque, lifting power and RER, leg extension power and vertical jump height. These results suggest that LST can increase muscle size and task-related strength, but has little effect on power production during dynamic explosive movements.

Dimethylarginine dimethylaminohydrolase 2 promotes tumor angiogenesis in lung adenocarcinoma

Although embryonal proteins have been used as tumor marker, most are not useful for detection of early malignancy. In the present study, we developed mouse monoclonal antibodies against fetal lung of miniature swine, and screened them to find an embryonal protein that is produced at the early stage of malignancy, focusing on lung adenocarcinoma. We found an antibody clone that specifically stained stroma of lung adenocarcinoma. LC-MS/MS identified the protein recognized by this clone as dimethylarginine dimethylaminohydrolase 2 (DDAH2), an enzyme known for antiatherosclerotic activity. DDAH2 was found to be expressed in fibroblasts of stroma of malignancies, with higher expression in minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma than in adenocarcinoma in situ (AIS). Moreover, tumors with high stromal expression of DDAH2 had a poorer prognosis than those without. In vitro analysis showed that DDAH2 increases expression of endothelial nitric oxide synthase (eNOS), inducing proliferation and capillary-like tube formation of vascular endothelial cells. In resected human tissues, eNOS also showed higher expression in invasive adenocarcinoma than in AIS and normal lung, similarly to DDAH2. Our data indicate that expression of DDAH2 is associated with invasiveness of lung adenocarcinoma via tumor angiogenesis. DDAH2 expression might be a prognostic factor in lung adenocarcinoma.

Genotype-Associated Differential NKG2D Expression on CD56+CD3+ Lymphocytes Predicts Response to Pegylated-Interferon/Ribavirin Therapy in Chronic Hepatitis C

Hepatitis C virus (HCV) genotype 1 infections are significantly more difficult to eradicate with PEG-IFN/ribavirin therapy, compared to HCV genotype 2. The aim of this work is to investigate the difference of immunological impairments underlying this phenomenon. Pre-treatment NKG2D expression on peripheral CD56+CD3+ lymphocytes and CD56+CD3- NK cells from cases of chronic hepatitis C were analyzed and assessed by treatment effect. Two strains of HCV were used to co-incubate with immune cells in vitro. NKG2D expression on peripheral CD56+CD3+ lymphocytes, but not NK cells, was significantly impaired in genotype 1 infection, compared to genotype 2. When peripheral blood mononuclear cells from healthy donors were co-incubated with TNS2J1, a genotype 1b/2a chimera strain, or with JFH1, a genotype 2a strain, genotype-specific decrease of NKG2D on CD56+CD3+ lymphocytes, but not NK cells, was observed.　Pre-treatment NKG2D expression on peripheral CD56+CD3+ lymphocytes significantly correlated with reduction in serum HCV RNA levels from week 0 to week 4, and predicted treatment response. Ex vivo stimulation of peripheral CD56+CD3+ lymphocytes showed NKG2D expression-correlated IFN-γ production. In conclusion, Decreased NKG2D expression on CD56+CD3+ lymphocytes in chronic HCV genotype 1 infection predicts inferior treatment response to PEG-IFN/ribavirin therapy compared to genotype 2.

Pregnant woman with non-comatose autoimmune acute liver failure in the second trimester rescued using medical therapy: A case report

We present the case of a 25-year-old woman at 16 weeks of gestation who presented with non-comatose autoimmune acute liver failure and was at high risk of developing fulminant hepatitis. Predictive formulas indicated a high probability of developing fulminant hepatitis. Unenhanced computed tomography showed marked hepatic atrophy and broadly heterogeneous hypoattenuating areas. The course of her illness was subacute, and the etiology of liver injury was unclear. Considering all of the above, we predicted a poor prognosis. Plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy were initiated just after admission. A few days after admission, a high titer (×80) of antinuclear antibody was noted. Because autoimmune hepatitis (AIH) was considered a cause of liver failure, treatment with moderate prednisolone (30 mg/day) doses was administrated, with careful consideration of her pregnancy. Thereafter, her laboratory findings and clinical course gradually improved without the need for liver transplantation. A liver biopsy at 18 days after admission indicated a diagnosis of AIH. She continued the pregnancy and delivered a healthy baby without any complications. Eventually, prednisolone doses were decreased to 10 mg, after which her liver function worsened. The second liver biopsy also indicated a diagnosis of AIH. Accordingly, low-dose prednisolone and azathioprine doses (50 mg/day) were administrated to recover her liver function, after which her liver function regained normalcy. This case illustrates that a pregnant woman with non-comatose autoimmune acute liver failure in the first or second trimester of pregnancy and her fetus can be rescued by PE/CHDF therapy and safe moderate doses of prednisolone.

Beneficial effect of an omega-6 PUFA-rich diet in non-steroidal anti-inflammatory drug-induced mucosal damage in the murine small intestine

AIM: To investigate the effect of a fat rich diet on non-steroidal anti-inflammatory drug (NSAID)-induced mucosal damage in the murine small intestine.

METHODS: C57BL6 mice were fed 4 types of diets with or without indomethacin. One group was fed standard laboratory chow. The other groups were fed a fat diet consisting of 8% w/w fat, beef tallow (rich in SFA), fish oil, (rich in omega-3 PUFA), or safflower oil (rich in omega-6 PUFA). Indomethacin (3 mg/kg) was injected intraperitoneally from day 8 to day 10. On day 11, intestines and adhesions to submucosal microvessels were examined.

RESULTS: In the indomethacin-treated groups, mucosal damage was exacerbated by diets containing beef tallow and fish oil, and was accompanied by leukocyte infiltration (P < 0.05). The mucosal damage induced by indomethacin was significantly lower in mice fed the safflower oil diet than in mice fed the beef tallow or fish oil diet (P < 0.05). Indomethacin increased monocyte and platelet migration to the intestinal mucosa, whereas safflower oil significantly decreased monocyte and platelet recruitment (P < 0.05).

CONCLUSION: A diet rich in SFA and omega-3 PUFA exacerbated NSAID-induced small intestinal damage via increased leukocyte infiltration. Importantly, a diet rich in omega-6-PUFA did not aggravate inflammation as monocyte migration was blocked.

Modified bowel preparation regimen for use in second-generation colon capsule endoscopy in patients with ulcerative colitis

BACKGROUND AND AIM

We have reported that second-generation colon capsule endoscopy (CCE-2) might be feasible for assessing the severity of mucosal inflammation in ulcerative colitis (UC). However, because of the low rate (69%) of complete evaluation of the colon and owing to inadequate cleansing. We believe that the method of bowel preparation could be improved by reducing volume. In the present study, we attempted to improve the colon-cleansing regimen in order to optimize the usefulness of CCE-2 in the management of UC patients.

METHODS

Twenty patients with histologically confirmed UC were enrolled. Patients took a maximum 2.2 L lavage solution (polyethylene glycol solution and magnesium citrate) in two or three divided doses. To assess the effectiveness of the modified bowel preparation regimen, we evaluated the rate of total colonobservation, the effectiveness of bowel cleansing, andinterobserver agreement in assessing UC disease activity. We used a four-point grading scale (poor, fair, good, and excellent) for evaluating the quality of bowel cleansing. Matts' endoscopic score was used to evaluate disease activity.

RESULTS

The rate of total colon observation was 85%, and 15 patients (75%) excreted the CCE-2 within 8 h. The proportion of excellent plus good cleansing was approximately 60%. There was a substantial interobserver agreement (κ = 0.777) in assessment of overall cleansing, which was still substantial at the fair cleansing level (κ = 0.700).

CONCLUSION

Using CCE-2, the modified bowel preparation regimen, with reduced volume has the potential to succeed in the evaluation of mucosal severity in UC.

Prominent steatosis with hypermetabolism of the cell line permissive for years of infection with hepatitis C virus

Most of experiments for HCV infection have been done using lytic infection systems, in which HCV-infected cells inevitably die. Here, to elucidate metabolic alteration in HCV-infected cells in a more stable condition, we established an HCV-persistently-infected cell line, designated as HPI cells. This cell line has displayed prominent steatosis and supported HCV infection for more than 2 years, which is the longest ever reported. It enabled us to analyze metabolism in the HCV-infected cells integrally combining metabolomics and expression arrays. It revealed that rate-limiting enzymes for biosynthesis of cholesterol and fatty acids were up-regulated with actual increase in cholesterol, desmosterol (cholesterol precursor) and pool of fatty acids. Notably, the pentose phosphate pathway was facilitated with marked up-regulation of glucose-6-phosphate dehydrogenase, a rete-limiting enzyme, with actual increase in NADPH. In its downstream, enzymes for purine synthesis were also up-regulated resulting in increase of purine. Contrary to common cancers, the TCA cycle was preferentially facilitated comparing to glycolysis pathway with a marked increase of most of amino acids. Interestingly, some genes controlled by nuclear factor (erythroid-derived 2)-like 2 (Nrf2), a master regulator of antioxidation and metabolism, were constitutively up-regulated in HPI cells. Knockdown of Nrf2 markedly reduced steatosis and HCV infection, indicating that Nrf2 and its target genes play important roles in metabolic alteration and HCV infection. In conclusion, HPI cell is a bona fide HCV-persistently-infected cell line supporting HCV infection for years. This cell line sustained prominent steatosis in a hypermetabolic status producing various metabolites. Therefore, HPI cell is a potent research tool not only for persistent HCV infection but also for liver metabolism, overcoming drawbacks of the lytic infection systems.

ECT2 amplification and overexpression as a new prognostic biomarker for early-stage lung adenocarcinoma

Genetic abnormality in early-stage lung adenocarcinoma was examined to search for new prognostic biomarkers. Six in situ lung adenocarcinomas and nine small but invasive adenocarcinomas were examined by array-comparative genomic hybridization, and candidate genes of interest were screened. To examine gene abnormalities, 83 cases of various types of lung carcinoma were examined by quantitative real-time genomic PCR and immunohistochemistry. The results were then verified using another set of early-stage adenocarcinomas. Array-comparative genomic hybridization indicated frequent amplification at chromosome 3q26. Of the seven genes located in this region, we focused on the epithelial cell transforming sequence 2 (ECT2) oncogene, as ECT2 amplification was detected only in invasive adenocarcinoma, and not in in situ carcinoma. Quantitative PCR and immunohistochemistry analyses also detected overexpression of ECT2 in invasive adenocarcinoma, and this was correlated with both the Ki-67 labeling index and mitotic index. In addition, it was associated with disease-free survival and overall survival of patients with lung adenocarcinoma. These results were verified using another set of early-stage adenocarcinomas resected at another hospital. Abnormality of the ECT2 gene occurs at a relatively early stage of lung adenocarcinogenesis and would be applicable as a new biomarker for prognostication of patients with lung adenocarcinoma.

Free cholesterol accumulation in hepatic stellate cells: mechanism of liver fibrosis aggravation in nonalcoholic steatohepatitis in mice

Although nonalcoholic steatohepatitis (NASH) is associated with hypercholesterolemia, the underlying mechanisms of this association have not been clarified. We aimed to elucidate the precise role of cholesterol in the pathophysiology of NASH. C57BL/6 mice were fed a control, high-cholesterol (HC), methionine-choline-deficient (MCD), or MCD+HC diet for 12 weeks or a control, HC, high-fat (HF), or HF+HC diet for 24 weeks. Increased cholesterol intake accelerated liver fibrosis in both the mouse models without affecting the degree of hepatocellular injury or Kupffer cell activation. The major causes of the accelerated liver fibrosis involved free cholesterol (FC) accumulation in hepatic stellate cells (HSCs), which increased Toll-like receptor 4 protein (TLR4) levels through suppression of the endosomal-lysosomal degradation pathway of TLR4, and thereby sensitized the cells to transforming growth factor (TGF)β-induced activation by down-regulating the expression of bone morphogenetic protein and activin membrane-bound inhibitor. Mammalian-cell cholesterol levels are regulated by way of a feedback mechanism mediated by sterol regulatory element-binding protein 2 (SREBP2), maintaining cellular cholesterol homeostasis. Nevertheless, HSCs were sensitive to FC accumulation because the high intracellular expression ratio of SREBP cleavage-activating protein (Scap) to insulin-induced gene (Insig) disrupted the SREBP2-mediated feedback regulation of cholesterol homeostasis in these cells. HSC activation subsequently enhanced the disruption of the feedback system by Insig-1 down-regulation. In addition, the suppression of peroxisome proliferator-activated receptor γ signaling accompanying HSC activation enhanced both SREBP2 and microRNA-33a signaling. Consequently, FC accumulation in HSCs increased and further sensitized these cells to TGFβ-induced activation in a vicious cycle, leading to exaggerated liver fibrosis in NASH.

CONCLUSION

These characteristic mechanisms of FC accumulation in HSCs are potential targets to treat liver fibrosis in liver diseases including NASH.