Six1 is down-regulated in end-stage human dilated cardiomyopathy independently of Ezh2.

BACKGROUND: Recently, it was shown that a knock-out (KO) of the polycomb histone methyltransferase Ezh2 leads to cardiac hypertrophy in mice, which was driven by the homeodomain transcription factor Six1. Here, we analyzed the expression of Six1 and its regulating factor Ezh2 in cardiac tissue of patients with end-stage dilative cardiomyopathy (DCM). METHODS: Tissue samples of patients with end-stage DCM (n = 35) were compared with controls (n = 12) for the protein expression of Ezh1, Ezh2, Six1, and a marker of protein expression p70S6K. RESULTS: Contrary to the Ezh2-KO mouse model, we found a down-regulation of Six1 (26%) and an up-regulation of Ezh2 (76%) in DCM hearts, (both P < 0.05). Expression of Ezh2 and Six1 did not correlate in human tissue (DCM: r2: 0.03, P = 0.31 and donor: r2: 0.05, P = 0.45). Expression of Six1 weakly correlated with left ventricular end-systolic diameter and fractional shortening. In DCM, Six1 also showed a positive correlation to the expression of the ribosomal protein p70S6K (r: 0.39, P = 0.029), which is involved in protein synthesis. This correlation was not seen in donor tissue, which showed a trend for a negative correlation (r: -0.49, P = 0.08). CONCLUSION: Our data indicate that the Ezh2/Six1 axis might be involved in human DCM. However, Six1 expression may be regulated by factors other than Ezh2, and more research is needed to determine the precise role of Ezh2/Six1 in human DCM.

TWIST1 regulates the activity of ubiquitin proteasome system via the miR-199/214 cluster in human end-stage dilated cardiomyopathy.

BACKGROUND: The transcription factor TWIST1 has been described to regulate the microRNA (miR)-199/214 cluster. Genetic disruption of TWIST1 resulted in a cachectic phenotype and early death of the knock-out mice. This might be connected to the activity of the ubiquitin-proteasome-system (UPS), as miR-199a has been suggested to regulate the ubiquitin E2 ligases Ube2i and Ube2g1. METHODS: Cardiac tissue from explanted hearts of 42 patients with dilated cardiomyopathy and 20 healthy donor hearts were analysed for protein expression of TWIST1 and its inhibitors Id-1, MuRF-1 and MAFbx, the expression of miR-199a, -199b and -214, as well as the activity of the UPS by using specific fluorogenic substrates. RESULTS: TWIST1 was repressed in patients with dilated cardiomyopathy by 43% (p=0.003), while Id1 expression was unchanged. This was paralleled by a reduced expression of miR-199a by 38 ± 9% (p=0.053), miR-199b by 36 ± 13% (p=0.019) and miR-214 by 41 ± 11% (p=0.0158) compared to donor hearts. An increased peptidylglutamyl-peptide-hydrolysing activity (p<0.0001) was observed in the UPS, while the chymotrypsin-like and trypsin-like activities were unchanged. The protein levels of the rate limiting ubiquitin E3-ligases MuRF-1 and MAFbx were up-regulated (p=0.005 and p=0.0156, respectively). Mechanistically silencing of TWIST1 using siRNA in primary rat cardiomyocytes led to a down-regulation of the miR-199/214 cluster and to a subsequent up-regulation of Ube2i. CONCLUSION: The TWIST1/miR-199/214 axis is down-regulated in dilated cardiomyopathy, which is likely to play a role in the increased activity of the UPS. This may contribute to the loss of cardiac mass during dilatation of the heart.

Non-HLA antibodies targeting vascular receptors enhance alloimmune response and microvasculopathy after heart transplantation.

BACKGROUND: Non-human leukocyte antigen antibodies (Abs) targeting vascular receptors are implicated in the pathogenesis of renal allograft vascular rejection and in progressive vasculopathy in patients with systemic sclerosis. METHODS: We prospectively tested in 30 heart transplant recipients the impact of Abs directed against endothelin-1 type A (ET(A)R) and angiotensin II type 1 receptors (AT(1)R, cell-enzyme-linked immunosorbent assay) at time of transplantation and during the first posttransplantation year on cellular and Ab-mediated rejection (immunohistochemistry, C3d, and immunoglobulins) and microvasculopathy in endomyocardial biopsy. RESULTS: Cellular rejection, Ab-mediated rejection, and microvasculopathy was found in 40% and 13%, 57% and 18%, and 37% and 40% of biopsies at 1 month and 1 year posttransplantation, respectively. Maximum levels of AT(1)R and ET(A)R Abs were higher in patients with cellular (16.5±2.6 vs. 9.4±1.3; P=0.021 and 16.5±2.5 vs. 9.9±1.9; P=0.041) and Ab-mediated rejection (19.0±2.6 vs. 10.0±1.3; P=0.004 and 19.4±2.7 vs. 9.0±1.7; P=0.002), as compared with patients who had no rejection. Patients with elevated AT(1)R Abs (53% [16/30]) or ETAR Abs (50% [15/30]; pretransplantation prognostic rejection cutoff >16.5 U/L) presented more often with microvasculopathy (both, 67% vs. 23%; P=0.048) than patients without. CONCLUSIONS: Elevated levels of AT(1)R and ET(A)R Abs are associated with cellular and Ab-mediated rejection and early onset of microvasculopathy and should be routinely monitored after heart transplantation.

Everolimus prevents endomyocardial remodeling after heart transplantation.

BACKGROUND: Endomyocardial remodeling is characterized by progressive fibrosis and scars and may develop after heart transplantation. The role of everolimus in preventing this process has not been evaluated as yet. METHODS: We prospectively studied 132 patients at baseline pretransplant and at 4 weeks, 1 year, and 3 years after heart transplantation. Fibrosis, scars (Zeiss Vision, in Sirius), and acute cellular rejection (hematoxylin-eosin) were studied in biopsy. Transplant vasculopathy was assessed by coronary angiography (focal stenoses, peripheral obliterations, negative vascular remodeling defined by peripheral obliterations, and diffusely narrowed proximal and mid vessel segments). RESULTS: Patients on everolimus versus patients on mycophenolate mofetil presented with significantly less fibrosis at 4 weeks (3.8%±0.3% vs. 5.5%±0.3%, P=0.007), 1 year (4.1%±0.3% vs. 4.8%±0.3%, P=0.015), and 3 years (4.2%±0.3% vs. 5.5%±0.7%, P=0.049) posttransplant and showed less scarring at 3 years posttransplant (19.9±1.9% vs. 31.9±4.6% vs. baseline biopsy 26.0±2.8%; P=0.017). Angiographic peripheral obliterations correlated with higher amounts of endomyocardial fibrosis. The negative correlation of everolimus and the positive correlation of peripheral obliterations with fibrosis were confirmed by regression analysis. Angiographic stenoses or acute cellular rejection had no effect on the development of fibrosis. Negative vascular remodeling in 1-year follow-up tended to be less frequent in everolimus-treated patients (24% vs. 76%; P=0.053). CONCLUSIONS: Everolimus prevents endomyocardial remodeling after heart transplantation and might have beneficial effects on vascular remodeling of epicardial coronary arteries too. Angiographic peripheral obliterations correlate with increased amounts of endomyocardial fibrosis, suggesting a relevant effect on microvascular perfusion.

Surgical treatment for active infective prosthetic valve endocarditis: 22-year single-centre experience.

OBJECTIVE: We retrospectively analysed the profile and outcome of surgically treated patients with active infective prosthetic valve endocarditis (PVE) over a period of 22 years. METHODS: Between May 1986 and December 2008, a total of 1313 patients with active infective endocarditis (AIE) were operated on, 349 (26.6%) of them for PVE. Of these, 77 (22.1%) had to be operated upon due to early PVE (≤60 days, n=55 men, median age: 58 years) and 272 (77.9%) due to late PVE (n=200 men, median age: 63 years). A large proportion of patients were referred to our department with advanced endocarditis and in a condition of cardiac and pulmonary decompensation. A total of 226 (64.8%) patients developed periannular abscess. Operations consisted of 80 aortic valve, 45 mitral valve, 39 double valve and 165 aortic root replacements, 134 of them with a homograft. Perioperative characteristics, probability of survival, freedom from recurrence and predictors for hospital mortality were analysed. Follow-up (maximum: 19.4 years) was completed in 96.3% (total: 1118 patient-years). RESULTS: There was high early and late mortality. Overall in-hospital mortality was 28.4% (99/349). The 30-day, 1-, 5- and 10-year survival for the whole PVE study population was 71.4 ± 2.4%, 58.7 ± 2.7%, 44.5 ± 3% and 31.7 ± 3.5% with no significant differences between the early and late PVE patients: 67 ± 5.4%, 55.9 ± 5.8%, 49.4 ± 6.2% and 29.7 ± 7.6%, compared to 72.4 ± 3%, 60 ± 3%, 43.5 ± 3.3% and 31.1 ± 3.8% (p=0.93). Predictors of early mortality were mechanical support (risk ratio (RR): 4.3), emergency operation (RR: 2.1), preoperative high doses of catecholamines (RR: 1.8), mitral valve replacement (RR: 1.5) and age at operation (RR: 1.1). Freedom from re-operation due to recurrent endocarditis at 10 years was 85.8 ± 5.6% for early PVE compared to 92.1 ± 2.3% for late PVE patients (p=0.17). Staphylococcus aureus (S. aureus) (18.1%) was the most frequent causative micro-organism. CONCLUSIONS: Surgery for active infective PVE continues to be challenging. It not only carries a high in-hospital mortality but is also associated with a high long-term mortality risk. Early PVE patients were in a more severe condition than late PVE patients. Preoperative status, complications and co-morbidity of PVE patients strongly predict early outcome. Because of the potential risk of late complications, PVE patients need close clinical follow-up.

Monoclonal antibody S60-4-14 reveals diagnostic potential in the identification of Pseudomonas aeruginosa in lung tissues of cystic fibrosis patients.

The lipopolysaccharide (LPS) of Pseudomonas aeruginosa has been identified to contain an inner-core structure expressing a Pseudomonas-specific epitope. This target structure is characterized by a highly phosphorylated and 7-O-carbamoyl-l-glycero-alpha-d-manno-heptopyranose (CmHep) and was found to be present in all human-pathogenic Pseudomonas species of the Palleroni (RNA)-classification I scheme. We raised and selected the monoclonal antibody S60-4-14 (mAb S60-4-14, subtype IgG1) from mice immunized with heat-killed Pseudomonas bacteria. The epitope of this mAb was found to reside in the inner-core structure of P. aeruginosa and, hence, successfully evaluated for the immunohistochemical detection of P. aeruginosa in formalin- or HOPE-fixed (Hepes-glutamic acid buffer-mediated organic solvent protection effect) and paraffin-embedded human lung tissue slices. Lung specimens, mainly from explanted lungs of cystic fibrosis (CF) patients, as well as P. aeruginosa isolates from patients suffering from CF and patients with extrapulmonar Pseudomonas infections were investigated by PCR, immunohistochemistry, and Western blot analysis with mAb S60-4-14. The results revealed an unequivocal coincidence of PCR and immunohistochemistry. Together with the Western blot results mAb S60-4-14 displays a potential diagnostic tool for the specific identification of P. aeruginosa in infected lungs of CF.

Bronchogenic cyst of the interatrial septum presenting as atrioventricular block.

Bronchogenic cysts are congenital lesions that are a remnant from abnormal budding of the embryonic foregut. These cysts are usually single; most cases are either asymptomatic or present with respiratory symptoms. A 43-year-old woman presented with intermittent type II atrioventricular block during cholecystectomy. The cardiac evaluation including transthoracic and transesophageal echocardiography and magnetic resonance imaging revealed a cystic homogeneous mass within the interatrial septum. The patient underwent surgical resection of the mass and closure of the septal defect. Histopathology identified ciliated columnar epithelium, consistent with the diagnosis of a bronchogenic cyst.

Aorticopulmonary paraganglioma with severe obstruction of the pulmonary artery: successful combined treatment by stenting and surgery.

Aorticopulmonary paraganglioma is a rare tumor of the middle mediastinum. Complete surgical resection is the only effective treatment, even when it may pose a surgical challenge due to the proximity of the tumor to the heart and great vessels, often rendering complete resection difficult to achieve. We report the case of a 30-year-old woman with an aorticopulmonary paraganglioma who presented with severe pulmonary hypertension due to obstruction of the pulmonary artery. In the first step, stenting of the pulmonary artery was performed and 2 months later a radical resection of the tumor using cardiopulmonary bypass under circulatory arrest and deep hypothermia was carried out. In addition, the ascending aorta and aortic arch were replaced by a prosthesis. The patient is in optimal condition and has now been disease-free for almost 7 years. We believe that this is the first description in the English literature of a successful combined management strategy in view of such an unusual manifestation of aorticopulmonary paraganglioma.

[Tip-Edge Plus bracket--a combination between Begg and Straight-Wire bracket--the best of both worlds with new horizons in fixed orthodontic therapy]. / Das Tip-edge Plus Bracket. Eine Kombination aus Begg und Straight-Wire Bracket. Das Beste aus zwei Welten mit neuen Optionen für die fixe orthodontische Therapie.

The Tip-Edge bracket was invented by Dr. P.C. Kesling (La Porte, Indiana, U.S.A.) in 1986. It introduced differential tooth movement within a modified Straight-Wire bracket system. The new Tip-Edge Plus bracket, first introduced in 2003, now uses superelastic Ni-Ti archwires (Deep Tunnel or Uprighting Wires) in Stage III instead of the Side-Winder springs for tip and torque. With Tip-Edge Plus, the average treatment time for extraction and non-extraction cases is 16 months, with 4 to 6 main archwires. Headgear, bite turbos and mini-implants are not required. The comfort for the patient and operator is increased, with less adjustments and shorter treatment time, resulting in a zero tolerance finish. This is because of the unique bracket architecture, which allows controlled tipping in one direction, while boosting anchorage in the other, with three-dimensional root control at the finish. Tip-Edge Plus Orthodontics is the fixed appliance of the 21st century and is in the education programmes of more than 55 dental shools worldwide.

Quilty in biopsy is associated with poor prognosis after heart transplantation.

We tested if Quilty (endocardial infiltration of lymphocytes) in routinely processed endomyocardial biopsy is associated with poor outcome after heart transplantation (HTx). Biopsies (n=9829) harvested within the first post-transplant year from 938 patients (778 men, mean age 49 years) were evaluated for Quilty and acute cellular rejection (according to the International Society for Heart and Lung Transplantation, ISHLT, classification). Transplant vasculopathy was evaluated by coronary angiography, and severe stenosis was found in 19% of patients. Survival was tested by Kaplan-Meier and Cox regression analyses for all-cause mortality and major cardiac events (lethal acute cellular rejection, graft loss or myocardial infarction). We found 1840 (19%) Quilty-positive biopsies in 487 Quilty-positive patients (52%). Quilty was more prevalent in women (p=0.038) and younger men (p=0.001), and was correlated with ISHLT grade 1R (OR 1.45, 95% CI 1.36-1.55; p<0.001) and ISHLT grade 2R (OR 2.48, 95% CI 2.21-3.41; p<0.001). Quilty in any biopsy was associated with a higher all-cause mortality (log rank p=0.045) due to a higher risk for major cardiac event (p=0.0001). Multivariate regression analysis showed Quilty (RR 1.69, 95%CI 1.05-2.73) and transplant vasculopathy (RR 2.78, 95%CI 1.68-4.61) as risk factors for major cardiac events and treated hyperlipidemia as lowering the risk for major cardiac events (RR 0.47, 95%CI 0.28-0.77). Quilty is associated with graft loss and poor outcome post HTx. Index biopsy during the first post-transplant year is a useful tool to identify patients at risk and is recommended during routine post-transplant management.

Beneficial effect of female gender on long-term survival after heart transplantation.

BACKGROUND: We aimed to test whether stenotic microvasculopathy affects the more beneficial course in female cardiac transplant recipients. METHODS: We studied 873 patients (35/151 premenopausal women aged < or =40 years) who underwent primary heart transplantation. In 7750 biopsies harvested within the first posttransplant year endothelial disease and stenotic microvasculopathy were evaluated by light microscopy (Hematoxylin and Eosin). Kaplan-Meier and Cox regression analyses were performed for major cardiac events (MACE; lethal myocardial infarction, sudden cardiac death, graft failure, and cardiac retransplantation). RESULTS: Stenotic microvasculopathy was found equally in men (38%) and women (39%). Allografts from premenopausal female-to-male transplants more frequently developed endothelial disease (78% vs. 65%; P=0.021) and stenotic microvasculopathy (46% vs. 28%, P=0.024). Beyond the first 5 posttransplant years women presented MACE less often than men, independently of donor gender and stenotic microvasculopathy (P=0.0001). Multivariate regression analysis found women to be at lower risk for MACE (Relative Risk [RR] 0.38; 95% Confidence Interval [CI] 0.17-0.81), whereas stenotic microvasculopathy (RR 2.15; 95% CI 1.42-3.26) and treated diabetes (RR 1.65; 95% CI 1.08-2.52) indicated a higher risk for MACE. CONCLUSIONS: Stenotic microvasculopathy has prognostic impact on survival of male and female cardiac recipients; however, it does not affect the more beneficial course of women in the long-term follow-up.

Isolated giant aortic aneurysm in an infant: Ehlers-Danlos syndrome type IV.

This report describes a successful surgical treatment of an isolated giant aneurysm of the ascending aorta and its arch in an 8-month-old infant.

Coronary flow reserve measurement detects transplant coronary artery disease in pediatric heart transplant patients.

BACKGROUND: Cardiac allograft vasculopathy (CAV) in patients who have undergone heart transplantation leads to graft dysfunction and is still the major concern for long-term survival. Evaluation of coronary flow velocity reserve (CFR) has been established for diagnosis of CAV. Systemic application of adenosine vs intracoronary testing for CFR has been validated in adults; however, its accuracy in pediatric patients has not yet been proven. METHODS: CFR was prospectively measured in 33 clinically asymptomatic pediatric heart transplant recipients. CFR measurements were made in the left anterior descending (LAD) artery using a 0.014-inch Doppler FloWire (Cardiometrics). CFR was defined as the ratio of hyperemic (after adenosine injection) to basal (before adenosine) average peak velocity (APV). Adenosine (Adrekar) was administered by intracoronary (15 or 30 mug bolus) and systemic (0.1 mg/kg) injection in each patient. Epicardial CAV was evaluated in coronary angiograms (Stanford criteria) and microvasculopathy was diagnosed in endomyocardial biopsies (evidence of luminal stenosis) blinded to clinical data. RESULTS: Thirty-three patients were included in this study. Their median age (range) was 11.9 (1.4 to 17) years and median post-transplant time 4.3 (1 to 11.7) years. Seventeen of the 33 patients had epicardial CAV (mainly peripheral obliterations or B1 and B2 lesions) and microvascular CAV. Epicardial CAV only was found in 4 patients and microvasculopathy only was present in only 1 patient. CFR was significantly reduced in patients with epicardial CAV and microvasculopathy when compared with patients without any signs of CAV: 206 +/- 53 vs 276 +/- 39 (p < 0.001) for the systemic application and 213 +/- 50 vs 271 +/- 45 (p = 0.004) for the intracoronary application. CONCLUSIONS: CFR and coronary vasoreactivity to adenosine are decreased in pediatric patients with CAV and correlate with histopathologic and angiographic evidence of microvascular disease. Measurement of CFR with intracoronary and systemic application of adenosine is comparable, while systemic application is necessary for non-invasive measurement of CFR in pediatric patients.

Quilty indicates increased risk for microvasculopathy and poor survival after heart transplantation.

BACKGROUND: The impact of Quilty (sub-endocardial infiltration of lymphocytes) on the development of stenotic microvasculopathy and outcome after heart transplantation has not yet been evaluated. METHODS: Biopsies (n = 9,713) obtained within the first post-transplant year from 873 patients (722 men, age 49.3 +/- 0.3 years) were evaluated by light microscopy (hematoxylin-eosin) for Quilty and cellular rejection (ISHLT), stenotic microvasculopathy (luminal radius:medial thickness ratio <1) and endothelial disease (core diameter:cell diameter ratio < or =1). Risk factors for stenotic microvasculopathy were analyzed by logistic regression. Overall survival and freedom from graft failure (cardiac re-transplantation, myocardial infarction and sudden cardiac death) were estimated by the Kaplan-Meier method and tested using a Cox proportional hazard model. RESULTS: We found 1,830 (19%) Quilty-positive biopsies in 481 (55%) Quilty-formers and stenotic microvasculopathy in 866 (9%) biopsies of 379 (43%) patients. Evidence of Quilty (odds ratio [OR] 1.77; 95% confidence interval [CI] 1.26 to 2.57) and endothelial disease (OR 4.98; 95% 95% CI 3.31 to 7.49) indicated higher risk, whereas post-transplant statin therapy was associated with lower risk for stenotic microvasculopathy (OR 0.68; 95% CI 0.48 to 0.97). Freedom from graft failure was lower in Quilty-formers (p = 0.0060) and even worse if patients suffered from both Quilty and stenotic microvasculopathy (p = 0.0017). Both factors were confirmed in multivariate regression analysis (stenotic microvasculopathy risk ratio [RR] 1.90, 95% CI 1.23 to 2.95; Quilty RR 1.77, 95% CI 1.11 to 2.82, p = 0.0430). CONCLUSIONS: Presence of Quilty indicates increased risk for stenotic microvasculopathy in biopsy early after heart transplantation. Both are associated with poor outcome due to graft failure.