Division Of Intramural Research Research Articles

Ex vivo sensitivity to broadly neutralizing antibodies and anti-CD4 antibody UB-421 of infectious viral isolates from people living with multidrug-resistant HIV

People living with HIV (PLWH) with multidrug-resistant (MDR) viruses have limited therapeutic options and present challenges regarding clinical management. Recent studies have shown that passive transfer of combination broadly neutralizing antibodies (bNAbs) against HIV and anti-domain 1 CD4 antibody UB-421 can sustain virologic suppression in PLWH in the absence of antiretroviral therapy (ART). Yet studies addressing the therapeutic potential of these antibodies and/or detailed characterization of immunologic and virologic parameters in PLWH with MDR HIV are lacking. We examined levels of immune activation and exhaustion markers on CD8+ T cells and the intact HIV proviral DNA burden in 11 PLWH with MDR viruses. For comparison purposes, we included a control group consisting of 27 ART-naïve viremic PLWH. In addition, we determined the sensitivity of infectious viral isolates obtained from the participants against eight bNAbs (3BNC117, 10-1074, VRC01, VRC07, N6, 10E8, PGDM1400, and PGT121) and two anti-CD4 antibodies (ibalizumab and UB-421) using a TZM-bl-based neutralization/suppression assay. The level of intact HIV proviral DNA was comparable between the two groups (P=0.29). The levels of activation and exhaustion markers PD-1 (P=0.0019), TIGIT (P=0.0222), 2B4 (P=0.0015), CD160 (P=0.0015), and CD38+/HLA-DR+ (P=0.0138) were significantly lower in the MDR group. The infectious viral isolates from each study participant with MDR HIV were resistant to at least 2 bNAbs; however, they were sensitive to at least one of the CD4-binding and non-CD4-binding site antibodies. The majority of participants had ibalizumab-sensitive viruses although the isolates from some participants showed reduced sensitivity to ibalizumab. Notably, none of the 93 viral isolates obtained from the participants were resistant to UB-421. Our data suggest that combination therapy with HIV-specific bNAbs and/or UB-421 in the presence of optimized background therapy could potentially provide sustained virologic suppression in PLWH with MDR HIV. However, this therapeutic strategy needs to be evaluated in human clinical trials. Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health.

Generation of an Inducible Avp Knockout Mouse Line Using CRISPR/Cas9 and Cre/LoxP

Background: Arginine vasopressin (AVP) is a peptide hormone coded by the Avp gene, synthesized in the hypothalamus and secreted by the posterior pituitary. Dysregulation of AVP secretion contributes to a variety of human diseases. Previous studies of functional roles of AVP have been largely dependent on the use of Brattleboro rats, which manifest a spontaneous mutation in the Avp gene and lack circulating AVP. Despite their utility, Brattleboro rats are diffcult to breed owing largely to the fixed nature of the Avp mutation, resulting in increased neonatal death and behavioral effects in the adults. Consequently, commercial breeders have ceased production, despite a continued need. To fill this need, we have now created a mouse model with a tamoxifen-inducible deletion of AVP. Methods: We employed CRISPR/Cas9 to target the desired regions (first intron and 3' downstream) within the Avp gene. Successful insertion of the two loxP sites was confirmed by PCR using primers flanking the targeted regions. Restriction enzymes BamHI or EcoRI were used to confirm correct targeting. For additional confirmation, PCR products were cloned into the TA-cloning vector and sequenced. Mice harboring the floxed allele were mated to B6.Cg-Tg(CAG-cre/Esr1*)5Amc/J mice that globally express a tamoxifen-inducible Cre recombinase. Results: The resultant homozygous conditional knockout mice ( Cre+ Avpflx/ flx) are viable, fertile, and show no signs of polydipsia or polyuria prior to induction, indicating that the conditional alleles retain their wild-type function. Induction of Cre-mediated recombination by administration of tamoxifen (2-3 mg q.d., i.p. for 5 days) in 8-week-old mice resulted in a decrease in urine osmolality from 2076±138 to 122±6 mOsm/kgH2O on day 31 after induction (p<0.0001). Sanger sequencing demonstrated the expected 1245 bp deletion at the Avp locus. The kidney parenchyma was structurally normal with no evidence of medullary atrophy 6 weeks after induction. Immunoblotting of AQP2 in the inner medulla showed a significant decrease in AQP2 band density in Cre+ Avpflx/ flx mice to 27±14 % of values in Cre− floxed control mice (p<0.05). Conclusion: We developed an inducible AVP knockout mouse line ( Cre+ Avpflx/ flx) that will be shared with the research community and are likely to be useful for further study of regulation of water balance and polycystic kidney disease, as well as neural, vascular, and metabolic roles of vasopressin. The work was funded by the Division of Intramural Research, National Heart, Lung and Blood Institute. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Development and Validation of a Protein Risk Score for Mortality in Heart Failure : A Community Cohort Study.

Heart failure (HF) is a complex clinical syndrome with high mortality. Current risk stratification approaches lack precision. High-throughput proteomics could improve risk prediction. Its use in clinical practice to guide the management of patients with HF depends on validation and evidence of clinical benefit. To develop and validate a protein risk score for mortality in patients with HF. Community-based cohort. Southeast Minnesota. Patients with HF enrolled between 2003 and 2012 and followed through 2021. A total of 7289 plasma proteins in 1351 patients with HF were measured using the SomaScan Assay (SomaLogic). A protein risk score was derived using least absolute shrinkage and selection operator regression and temporal validation in patients enrolled between 2003 and 2007 (development cohort) and 2008 and 2012 (validation cohort). Multivariable Cox regression was used to examine the association between the protein risk score and mortality. The performance of the protein risk score to predict 5-year mortality risk was assessed using calibration plots, decision curves, and relative utility analyses and compared with a clinical model, including the Meta-Analysis Global Group in Chronic Heart Failure mortality risk score and N-terminal pro-B-type natriuretic peptide. The development (n = 855; median age, 78 years; 50% women; 29% with ejection fraction <40%) and validation cohorts (n = 496; median age, 76 years; 45% women; 33% with ejection fraction <40%) were mostly similar. In the development cohort, 38 unique proteins were selected for the protein risk score. Independent of ejection fraction, the protein risk score demonstrated good calibration, reclassified mortality risk particularly at the extremes of the risk distribution, and showed greater clinical utility compared with the clinical model. Participants were predominantly of European ancestry, potentially limiting the generalizability of the findings to different patient populations. Validation of the protein risk score demonstrated good calibration and evidence of predicted benefits to stratify the risk for death in HF superior to that of clinical methods. Further studies are needed to prospectively evaluate the score's performance in diverse populations and determine risk thresholds for interventions. Division of Intramural Research at the National Heart, Lung, and Blood Institute of the National Institutes of Health.

The Phase 3 Natron Study Evaluating Benralizumab in Patients with Hypereosinophilic Syndrome: Study Design and Patient Characteristics

Background and Significance: Hypereosinophilic syndrome (HES) is a rare, heterogeneous disorder defined by blood eosinophilia (absolute eosinophil count [AEC] &amp;gt;1500 cells/μL) on 2 examinations ≥1 month apart and eosinophil-mediated end-organ involvement, including dermatologic, pulmonary, gastrointestinal, and/or cardiovascular manifestations. Symptoms and health-related quality of life vary depending on the organ systems involved. HES is often treated with corticosteroids and other immunosuppressants. However, long-term use of these agents is associated with decreased efficacy and significant toxicity. Whereas anti-IL-5 antibody mepolizumab was recently approved for the treatment of HES (Roufosse, et al. J Allergy Clin Immunol. 2020;146(6):1397-1405), response is not universal and additional targeted agents are clearly warranted. Benralizumab is a humanized, afucosylated, anti-interleukin-5 receptor α monoclonal antibody that induces rapid, near-complete depletion of eosinophils through antibody-dependent, cell-mediated cytotoxicity. It is currently approved for use in patients with severe eosinophilic asthma and has demonstrated AEC-reducing effects in patients with HES (Kuang, et al. N Engl J Med. 2019;380(14):1336-46). Study Design and Methods:This phase 3, multicenter, randomized, double-blind (DB), placebo-controlled study (NATRON; NCT04191304) evaluating the efficacy of benralizumab versus placebo will enroll ~120 patients with documented HES (Figure 1A). Recruitment will stop after approximately 38 patients have had their first HES worsening/flare during the DB period, at which point the data cutoff for the primary analysis will occur. Eligible patients are ≥12 years of age with an AEC ≥1000 cells/mL at screening, have active signs/symptoms of an HES worsening/flare or a history of ≥2 HES worsening/flares within 12 months before enrollment, and have a stable treatment regimen (≥4 weeks). Patients must be FIP1L1-PDGFRA-negative and corticosteroid-responsive, defined as an AEC of &amp;lt;1000 cells/μL after 2 days of corticosteroid treatment. The primary endpoint is time to first HES worsening/flare during the DB period. Key secondary endpoints during the DB period include the proportion of patients who experience HES worsening/flare events, the number of HES worsening/flare events (annualized rate/year), time to first hematologic relapse, and change from baseline in fatigue at week 24 as assessed by the Patient-Reported Outcomes Measurement Information System (PROMIS) Fatigue Short Form 7a. Patients who complete the 24-week DB treatment period will continue with active treatment in a ≥52-week open-label extension. We present the study design and interim baseline characteristics of patients recruited to date. Results:As of the June 6, 2023, cutoff date, 87 patients were enrolled in the full analysis set (Figure 1B). Among these patients, the mean (SD) age was 48.4 (17.79) years, 64.4% were female, and 84.3% were White. The mean (SD) time since the first appearance of HES symptoms and since HES diagnosis was 8.14 (8.12) and 4.87 (6.54) years, respectively. The proportion of patients with the lymphocytic variant HES was 14.9%. The most common primary organs involved were the lungs (35.6%), followed by the skin (25.3%) and the gastrointestinal tract (21.8%). Thirty-four (39.1%) and 32 (36.8%) patients experienced 2 and ≥3 HES worsening/flare events in the previous 12 months, respectively. The mean (SD) PROMIS Fatigue T-score was 55.0 (9.42). Mean (SD) baseline eosinophil levels were 1960 (2610) cells/µL, with median (interquartile range) levels of 1120 (60, 20910) cells/µL. Conclusions: Results from the NATRON study will provide insight into whether benralizumab is beneficial in addition to background therapy in patients with FIP1L1-PDGFRA-negative steroid-responsive HES. Funding: This study is funded by AstraZeneca (Gothenburg, Sweden). This work is funded in part by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Acknowledgments:Vivian H. Shih, Dianne Griffis, Himanshu Parikh, Ron A. Chen, Ying Fan, Gaëll Mayer, Rohit Katial, and Ioannis Psallidas.

Benralizumab for eosinophilic gastritis: a single-site, randomised, double-blind, placebo-controlled, phase 2 trial

In eosinophilic gastrointestinal diseases, the role of eosinophils in disease pathogenesis and the effect of eosinophil depletion on patient outcomes are unclear. Benralizumab, an eosinophil-depleting monoclonal antibody that targets the interleukin-5 receptor α, might eliminate gastric tissue eosinophils and improve outcomes in eosinophilic gastritis. We aimed to assess the efficacy and safety of benralizumab in patients with eosinophilic gastritis. We conducted a single-site, randomised, double-blind, placebo-controlled, phase 2 trial at Cincinnati Children's Hospital Medical Center (Cincinnati, OH, USA). Individuals aged 12-60 years with symptomatic, histologically active eosinophilic gastritis (peak gastric eosinophil count ≥30 eosinophils per high-power field [eos/hpf] in at least five hpfs) and blood eosinophilia (>500 eosinophils per μL [eos/μL]) were randomly assigned (1:1, block size of four) to benralizumab 30 mg or placebo, stratified by the use of glucocorticoids for gastric disease. Investigators, study staff, and study participants were masked to treatment assignment; statisticians were unmasked when analysing data. Treatments were administered subcutaneously once every 4 weeks for a 12-week double-blind period (three total injections). The primary endpoint was the proportion of patients who achieved histological remission (peak gastric eosinophil count <30 eos/hpf) at week 12. Key secondary endpoints were the changes from baseline to week 12 in peak gastric eosinophil count, blood eosinophil count, eosinophilic gastritis histology (total, inflammatory, and structural feature scores), Eosinophilic Gastritis Endoscopic Reference System (EG-REFS) score, and patient-reported outcome symptom measures (Severity of Dyspepsia Assessment [SODA] and Patient-Reported Outcome Measurement Information System [PROMIS] short-form questionnaire). After the 12-week double-blind period, patients were eligible for entry into two open-label extension (OLE) periods up to week 88, in which all patients received benralizumab. Efficacy was analysed in the intention-to-treat (ITT) population and safety was assessed in all patients who received at least one dose of study drug. The trial was registered on ClinicalTrials.gov, NCT03473977, and is completed. Between April 23, 2018, and Jan 13, 2020, 34 patients were screened, and 26 were subsequently randomly assigned to benralizumab (n=13) or placebo (n=13) and included in the ITT and safety populations (mean age 19·5 years [SD 7·3]; 19 [73%] male patients and seven [27%] female patients). At week 12, ten (77% [95% CI 50 to 92]) of 13 patients who received benralizumab and one (8% [1 to 33]) of 13 who received placebo achieved histological remission (difference 69 percentage points [95% CI 32 to 85]; p=0·0010). Changes from baseline to week 12 were significantly greater in the benralizumab group versus the placebo group for peak gastric eosinophil counts (mean -137 eos/hpf [95% CI -186 to -88] vs -38 eos/hpf [-94 to 18]; p=0·0080), eosinophilic gastritis histology total score (mean -0·31 [-0·42 to -0·20] vs -0·02 [-0·16 to 0·12]; p=0·0016), histology inflammatory score (mean -0·46 [-0·60 to -0·31] vs -0·04 [-0·22 to 0·13]; p=0·0006), and blood eosinophil counts (median -1060 eos/μL [IQR -1740 to -830] vs -160 eos/μL [-710 to 120]; p=0·0044). Changes were not significantly different between the groups for eosinophilic gastritis histology structural score (mean -0·07 [95% CI -0·19 to 0·05] vs 0·03 [-0·09 to 0·15]; p=0·23), EG-REFS score (mean -1·0 [-2·3 to 0·3] vs -0·5 [-2·0 to 1·0]; p=0·62), or in patient-reported outcomes (SODA and PROMIS). During the double-blind period, treatment-emergent adverse events occurred in 11 (85%) of 13 patients in the benralizumab group and six (46%) of 13 in the placebo group; the most common treatment-emergent adverse events were headache (six [46%] vs two [15%] patients), nausea (three [23%] vs two [15%]), and vomiting (two [15%] vs three [23%]). There were no treatment-related deaths. Two patients had serious adverse events (dizziness and rhabdomyolysis in one patient; aspiration in one patient) during the OLE periods, which were considered unrelated to study treatment. Benralizumab treatment induced histological remission, as defined by absence of tissue eosinophilia, in most patients with eosinophilic gastritis. However, the persistence of histological, endoscopic, and other features of the disease suggest a co-existing, eosinophil-independent pathogenic mechanism and the need for broader targeting of type 2 immunity. AstraZeneca and the Division of Intramural Research (National Institute of Allergy and Infectious Diseases, US National Institutes of Health).

Eos is a critical transcription factor for T regulatory cell (Treg) function

Abstract Eos is a member of the Ikaros transcription factor family and is highly expressed in Tregs. Mice with a selective deficiency of Eos in Treg develop systemic or organ-specific autoimmune disease at at a young age. We have generated a specific anti-Eos monoclonal antibody. The percentage of Tregs expressing Eos rapidly increases with aging from almost 0% at birth to 30~50% of thymic Tregs and 35~60% of splenic Tregs at 3 weeks of life and then remains stable. Eos is expressed at very low levels on induced Tregs, conventional CD4 +T cells and CD8 +T cells in vivo or in vitro. In the thymus, Eos is only expressed on CD73 +CCR6 +CXCR4 +Tregs, which suggests that Eos +thymic Tregs represent peripheral Tregs that have recirculated to the thymus. In thymus, Eos expression on Tregs is also highly correlated with CXCR4 and CCR6. Using these markers, we sorted Eos +and Eos −Tregs and in vitro expanded them using anti-CD3/CD28 beads and IL-2; Eos expression remained stable. Using immunofluorescence microscopy, we have found that Eos is highly co-localized with Helios, another Ikaros family member and HDAC1, but not other Ikaros family members including Ikaros or Aiolos, suggesting that Eos and Helios may form heterodimers and together with HDAC1 collaborate in Treg function. Nevertheless, expression of Eos is independent of Helios and vice versa, as Treg from Helios deficient mice express normal or elevated levels of Eos, and Treg from Eos deficient mice express normal levels of Helios. Taken together, these strongly suggest that Eos plays a related, but distinct role, from Helios in Treg function. This work was supported by Division of Intramural Research (DIR), NIAID, NIH.

Generation of thymic epithelial progenitor cells from induced pluripotent stem cells obtained from patients with thymic defects

Abstract Thymic epithelial cells (TECs) play a critical role in T-cell development as they provide essential cues to hematopoietic progenitors for their proliferation and differentiation in the thymus. Patients with genetic mutations affecting TEC functionality present with reduced thymus development and decreased T-cell output in the periphery. We have previously reported that T-cell development is blocked in patients with hematopoietic-intrinsic genetic defects using an artificial thymic organoid system, but this model does not allow testing of TEC defects. To address this, we have generated multiple induced pluripotent stem cell (iPSC) lines from patients carrying mutations on genes involved in thymic stromal development and/or function, including 22q11.2del (DiGeorge syndrome), CHD7, FOXI3, PAX1, AIRE, EXTL3, and TP63. We aim to differentiate these iPS lines into TECs and assess whether these mutations alter TEC generation. We are currently testing previously published protocols. However, most of these protocols focused on generating TECs from embryonic stem cells and were not optimized for human iPSCs. To address this, we are comparing and combining different methods to achieve a high efficiency in inducing definitive endoderm (DE), ventral pharyngeal endoderm (VPE) and finally thymic epithelial progenitors (TEP). We have already successfully reached the DE stage, as gene expression analysis by qPCR shows upregulation of genes associated with the DE and downregulation of iPS genes. Once we successfully generate TECs, we plan to incorporate them into our artificial thymic organoid system to create a model that will be solely based on human cells, obtaining a more accurate in vitroreflection of human thymic T cell development. This work was supported by the Division of Intramural Research (DIR), NIAID, NIH

Artificial thymic organoids generated with peripheral blood CD34 +cells represent a quick and powerful tool to determine the nature of severe T cell lymphopenia

Abstract The study of early T-cell development in humans is challenging because of the scarce availability of thymic samples and limitations of in vitro T-cell differentiation assays. We have previously shown that artificial thymic organoids (ATOs), generated by aggregating DLL4-expressing stromal cells with CD34 +cells isolated from bone marrow (BM) or mobilized peripheral blood (MPB), are a reliable tool to determine the hematopoietic-intrinsic or extrinsic nature of severe T-cell lymphopenia. However, BM or MPB samples are not often available and delays in obtaining these samples might dangerously postpone the patient’s clinical management decision. We thus set out to evaluate whether we could obtain reliable results from ATOs generated with CD34 +cells isolated from PB. The main challenge of using CD34 +cells from un-mobilized PB is that the frequency of these cells is much lower than that found in BM or MPB. For the generation of ATOs with BM or MPB CD34 +cells we used a minimum of 5000 cells/ATO, but these numbers would not be feasible for PB samples. We thus generated ATOs with decreased numbers of CD34 +cells, and we determined that 1000 cells/ATO was the minimum necessary to achieve efficient T-cell differentiation. Additionally, we slightly modified the experimental protocol and added SCF for the first 3 weeks of culture, in addition to IL7 and FLT3L, which are present throughout the T-cell differentiation assay. We also established that we could efficiently generate ATOs when starting from fresh blood (up to 3–4 days) and a minimum amount of 5–7 ml, for infants and early pediatric samples. Reduced efficiency in ATO generation was however obtained when isolating CD34 +cells from PB drawn more that 5–6 days earlier or from frozen samples. This work was supported by the Division of Intramural Research, NIAID, NIH.

Immuno-skeletal Dysplasia with Neurodevelopmental Abnormalities complicated with Omenn Syndrome in a case of a compound heterozygous variants of exostosin-like 3 gene

IntroductionSevere combined immunodeficiency (SCID) encompasses over thirty monogenic disorders. Exostosin like glycosyltransferase 3 (EXTL3) is a ubiquitously expressed gene encoding an enzyme involved in the synthesis of heparan sulfate. EXTL3 deficiency results in an ultra-rare autosomal recessive condition called Immuno-skeletal Dysplasia with Neurodevelopmental Abnormalities (ISDNA).This report describes a patient with compound heterozygous variants in the EXTL3 gene with ISDNA. Case DescriptionA 2-week-old Caucasian full-term male with multiple dysmorphisms (Table 1), in-utero ischemic brain injury, and discoordinated feeding admitted to the Neonatal Intensive Care Unit was noted to have undetectable T-cell receptor excision circle (TREC) on his newborn screen. The workup revealed profound T-cell deficiency, undetectable CD4+CD45RA+CD31+ cells (CD4RTE), and normal CD19+ B- and CD16+/CD56+ NK-cell counts (Figure 1). Trio rapid genome sequencing, including non-consanguineous parents, detected compound heterozygous variants in the EXTL3 gene (Figure 2). [Display omitted] [Display omitted] Table 1Clinical signs and symptoms observed in the caseSystemClinical signsFacial/AxialUpslanted palpebral fissures, epicanthal foldsDepressed nasal bridgePosteriorly rotated earsSmooth philtrumCleft soft palateMicrognathia and retrognathiaWidely spaced nipplesAppendicular skeletonClinodactyly of left 5th toe and overriding 3rd and 4thleft toesNeurologyMicrocephalyGeneralized hypotoniaSuckling difficultyGastrointestinalGastroesophageal refluxHepatic cystsGallstonesDiarrheaGrowth parameters at birth (per WHO chart)Length: 6.38 percentileWeight: 72.3 percentileHead Circumference: 27.4 percentileAt six weeks of age, the patient developed Omenn syndrome, characterized by diarrhea, scaly maculopapular rash, and a rise in his T-cell and eosinophil count. He was treated with cyclosporine and steroids with a good response to therapy. He required gastric tube placement for poor oropharyngeal coordination and was started on ursodeoxycholid acid for gallstones (Table 1).The artificial thymic organoid (ATO) platform test (NIH Protocol # NCT03610802, LDN is supported by the Division of Intramural Research, NIAID, NIH) indicated that the patient had no hematopoietic cell autonomous defects in the ability of CD34+ cells to differentiate into mature T cells in ATO, suggesting extra-hematopoietic causes of T-cell lymphopenia. He is currently undergoing an evaluation for a thymic transplant. ConclusionTo our knowledge, this is the sixteenth reported case of ISDNA, and the first caused by compound heterozygous variants of EXTL3. In the fifteen previously reported cases, facial dysmorphism and abnormalities in the skeletal system were consistently observed. In contrast, the degree and frequency of the immune and neurological impairment varied. Furthermore, our case describes an extensive gastrointestinal impairment in ISDNA, and the benefits of ATO in guiding curative therapy for SCID.

Investigating a Role for Eosinophils in the Immune Response to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)

Abstract Eosinophils rapidly decrease in the peripheral blood of patients during COVID-19, and eosinopenia has been correlated with disease severity. These clinical observations suggest that eosinophils may play a functional role in the response to SARS-CoV-2 infection. Murine studies have shown that eosinophils can be recruited to the lungs in response to infection with respiratory viruses, including RSV and influenza and parainfluenza viruses, yet the role of eosinophils in the lungs in response to SARS-CoV-2 infection is unknown. Here, we used a two-pronged approach employing mouse models of SARS-CoV-2 infection to study the role of eosinophils in the antiviral immune response and viral control and clinical samples to assess eosinophilia and eosinophil activation in patients during and after COVID-19. Our initial findings indicate that eosinophils are recruited to the lungs after SARS-CoV-2 infection in mice and that eosinophil-deficient mice may have increased lung viral titers early after infection. In keeping with this hypothesis, serum levels of eosinophil granule proteins (a marker of tissue eosinophilia) were increased during active SARS-CoV-2 infection in patients participating in a long-term follow-up study of COVID-19, at a time when eosinophil counts were depressed. These preliminary data suggest that eosinophils may have a protective role in early anti-viral host defense during SARS-CoV-2 infection in mice and that further studies are required to better understand the relative roles of eosinophils in protection and pathology to SARS-CoV-2 infection. Funding for this study was provided in part by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health.

Autoantibodies produced by SARS-CoV-2 infection trigger damage to the lacrimal and salivary glands and lead to the development of Sjögren’s Disease

Abstract Sjögren’s Disease (SjD) is a chronic, systemic autoimmune disease characterized by lymphocytic infiltration and the development of dry eyes and mouth as the result of the secretory dysfunction of the lacrimal and salivary glands. In recent years, infectious agents have been shown to be associated with SjD. Several studies indicated that SARS-CoV-2 infection induces autoantibodies production, patients also experienced various autoimmune disorders. This study used SARS-CoV-2 WA1/2020 to infect hACE2 mice to investigate the relationship between SARS-CoV-2 infection and SjD. Infected mice showed dry eyes, decreased salivary flow, lymphocytic infiltration of the lacrimal and salivary glands, elevated antinuclear antibodies (ANA), specifically anti-SSB/La, and apoptotic cells near the acinar cells. Notably, counting of apoptotic cells showed a significantly higher number in the lacrimal glands of mice infected with a low viral load than high viral load. We confirmed with clinical data that we observed the elevation of SjD-specific autoantibodies (ANA, anti-SSB/Ro52, and anti-SSA/La) in sera from COVID-19 patients. Salivary gland biopsies of patients diagnosed with SjD several months after SARS-CoV-2 infection also showed lymphocytic infiltration and fibrosis. Lastly, to identify whether monoclonal antibodies produced by COVID-19 patients are reactive against nuclear antigens, antibodies tested for greater antiviral binding capacity were shown to be more responsive. Overall, by observing SjD-like phenotypes in mouse models and patients, our study confirms a direct pathogenic role of SARS-CoV-2 in SjD. It also provides a different pilot for the study of the mechanisms of autoimmune responses induced by viral infections. This research was funded by the National Institutes of Health (NIH), National Institute of Dental and Craniofacial Research (NIDCR), Division of Extramural Research (DE028544, PI-Nguyen; DE028544-02S1, PI-Nguyen), and the NIH/NIDCR Division of Intramural Research (Z01-DE000704, PI-Warner; Z01-DE00695, PI-Chiorini).

Kupffer cells heterogeneity and replacement by monocyte-derived KCs contributes to visceral leishmaniasis resistance

Abstract Visceral leishmaniasis (VL) is a potentially fatal disease transmitted by sand fly bites and caused by Leishmania (L. donovani/L. infantum) protozoa. Kupffer cells (KCs) are the liver embryonic resident macrophages (emKCs), characterized by Clec4f and Tim4 expression and their sessile behavior within the liver sinusoids. KCs maintain their numbers via self-proliferation during homeostasis but can be replaced by monocyte-derived cells (moKCs) during inflammation. In the murine VL model, KCs are important for both initial parasite growth and granuloma formation, the latter being associated with the eventual protective response. The objective of our study is to investigate KC proliferation, migration, death, and their replacement by moKCs in VL. We found that KC proliferation was enhanced at 19 d.p.i., while at 42 d.p.i. the granulomas cores contained mixed KC clonal lineages and were located outside the liver sinusoids. At the same time point, Clec4f and Tim4 expression was reduced, and we found evidence of KC apoptosis and ferroptosis. Parabiotic mice demonstrated KC populations that bore either congenic marker, and CCR2 −/−infected mice showed enhanced frequencies of emKCs, reduced frequencies of moKCs, and higher parasite loads compared to WT mice. Reduction of ferroptosis in BACH1 −/−mice resulted in lower frequencies of moKCs. Collectively, our data indicates that KCs migrate to the liver parenchyma to form granulomas, facilitating their activation by other immune cells, and that KC death results in their partial replacement by moKCs, contributing to increased parasite killing. Thus, KC heterogeneity is an important hallmark of hepatic resistance in VL. Funded by the Division of Intramural Research, NIAID.

Evaluation of cutaneous immune response in a controlled human in vivo model of mosquito bites

Abstract Mosquito-borne viruses are a growing global threat. Initial viral inoculation occurs in the skin via the mosquito ‘bite’, eliciting immune responses that shape the establishment of infection and pathogenesis. Here we assess the cutaneous innate and adaptive immune responses to controlled Aedes aegypti feedings in humans living in Aedes-endemic areas. In this single-arm, cross- sectional interventional study (trial registration #NCT04350905), we enroll 30 healthy adult participants aged 18 to 45 years of age from Cambodia between October 2020 and January 2021. We perform 3-mm skin biopsies at baseline as well as 30 min, 4 h, and 48 h after a controlled feeding by uninfected Aedes aegypti mosquitos. The primary endpoints are measurement of changes in early and late innate responses in bitten vs unbitten skin by gene expression profiling, immunophenotyping, and cytokine profiling. The results reveal induction of neutrophil degranulation and recruitment of skin-resident den- dritic cells and M2 macrophages. As the immune reaction progresses T cell priming and regulatory pathways are upregulated along with a shift to Th2-driven responses and CD8+ T cell activation. Stimulation of participants’ bitten skin cells with Aedes aegypti salivary gland extract results in reduced pro-inflammatory cytokine production. These results identify key immune genes, cell types, and pathways in the human response to mosquito bites and can be leveraged to inform and develop novel therapeutics and vector- targeted vaccine candidates to interfere with vector-mediated disease. Division of Intramural Research at National Institute of Allergy and Infectious Diseases at the National Institutes of Health #1ZIAAI001066-12: J.M., F.O.; Howard Hughes Medical Institute-Wellcome #208710/Z/17/Z: T.C.; French National Research Agency #ANR-17-CE15-00029: D.M.; Calmette-Yersin PhD Scholarship: D.G.

A new pipeline denoted SPICE identifies novel JUN-IKZF1 composite elements

Abstract DNA composite elements allow combinatorial transcription factor binding, which is important for fine tuning gene expression in response to physiological stimuli and in pathological conditions. Moreover, composite elements may contribute to epigenetic regulation. Accordingly, developing screening algorithms to identify novel composite elements and their compositions is crucial. Here we report a pipeline termed Spacing Preference Identification of Composite Elements (SPICE), that systematically predicts novel protein binding partners along with their DNA motifs and spacing preferences in a genome wide fashion. Besides predicting known composite elements like AP1-IRF composite elements (AICE) and STAT5 tetramers, SPICE de novo predicted a range of novel binding partners, including JUN-IKZF1 composite elements. We validated JUN-IKZF1 association by co-immunoprecipitation and showed cooperative binding of these factors to an upstream conserved noncoding region, CNS9, in the human IL10 gene based on electrophoretic mobility shift assays. Furthermore, the activity of an IL10 luciferase reporter depended on both AP1 and IKZF1 binding sites within this composite element in mouse B and T cells, confirming its transcriptional relevance. These data establish SPICE as a valuable pipeline for predicting novel transcription factor complexes that regulate gene transcription and provide insights into the biological cooperation of IKZF1 and AP1. Division of Intramural Research, NHLBI.

Centering Patient Voices Through Community Engagement in Cardiovascular Research.

HomeCirculationVol. 147, No. 2Centering Patient Voices Through Community Engagement in Cardiovascular Research No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextCentering Patient Voices Through Community Engagement in Cardiovascular Research Tiffany M. Powell-Wiley, MD, MPH Tiffany M. Powell-WileyTiffany M. Powell-Wiley Correspondence to: Tiffany M. Powell-Wiley, MD, MPH, Building 10, Room 5-5332, 10 Center Dr, Bethesda, MD 20892. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9488-4131 Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, and Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Search for more papers by this author Originally published9 Jan 2023https://doi.org/10.1161/CIRCULATIONAHA.122.061112Circulation. 2023;147:105–107FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 107.Correspondence to: Tiffany M. Powell-Wiley, MD, MPH, Building 10, Room 5-5332, 10 Center Dr, Bethesda, MD 20892. Email tiffany.[email protected]gov

Transcatheter Myotomy to Treat Hypertrophic Cardiomyopathy and Enable Transcatheter Mitral Valve Replacement: First-in-Human Report of Septal Scoring Along the Midline Endocardium.

HomeCirculation: Cardiovascular InterventionsVol. 15, No. 6Transcatheter Myotomy to Treat Hypertrophic Cardiomyopathy and Enable Transcatheter Mitral Valve Replacement: First-in-Human Report of Septal Scoring Along the Midline Endocardium No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessCase ReportRequest AccessFull TextTranscatheter Myotomy to Treat Hypertrophic Cardiomyopathy and Enable Transcatheter Mitral Valve Replacement: First-in-Human Report of Septal Scoring Along the Midline Endocardium Adam B. Greenbaum, MD, Jaffar M. Khan, PhD, BM BCh, Christopher G. Bruce, MB ChB, George S. Hanzel, MD, Patrick T. Gleason, MD, Keshav Kohli, PhD, Errol K. Inci, MD, Robert A. Guyton, MD, Gaetano Paone, MD, Toby Rogers, PhD, BM BCh, Robert J. Lederman, MD and Vasilis C. Babaliaros, MD Adam B. GreenbaumAdam B. Greenbaum Correspondence to: Adam B. Greenbaum, MD, Emory Structural Heart and Valve Center, 550 Peachtree St NE, 4th Floor, Davis-Fischer Bldg, Atlanta, GA 30308. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7496-5954 Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Jaffar M. KhanJaffar M. Khan https://orcid.org/0000-0001-6099-0753 Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (J.M.K., C.G.B., T.R., R.J.L.). Search for more papers by this author , Christopher G. BruceChristopher G. Bruce https://orcid.org/0000-0002-7442-4303 Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (J.M.K., C.G.B., T.R., R.J.L.). Search for more papers by this author , George S. HanzelGeorge S. Hanzel https://orcid.org/0000-0003-3041-5947 Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Patrick T. GleasonPatrick T. Gleason https://orcid.org/0000-0001-5739-9030 Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Keshav KohliKeshav Kohli https://orcid.org/0000-0002-1469-4088 Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Atlanta (K.K.). Search for more papers by this author , Errol K. InciErrol K. Inci https://orcid.org/0000-0002-4449-444X Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Robert A. GuytonRobert A. Guyton Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Gaetano PaoneGaetano Paone Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). Search for more papers by this author , Toby RogersToby Rogers https://orcid.org/0000-0002-6043-3137 Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (J.M.K., C.G.B., T.R., R.J.L.). Search for more papers by this author , Robert J. LedermanRobert J. Lederman https://orcid.org/0000-0003-1202-6673 Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (J.M.K., C.G.B., T.R., R.J.L.). *R.J. Lederman and V.C. Babaliaros contributed equally. Search for more papers by this author and Vasilis C. BabaliarosVasilis C. Babaliaros https://orcid.org/0000-0002-9438-0846 Emory Structural Heart and Valve Center, Emory University, Atlanta, GA (A.B.G., G.S.H., P.T.G., E.K.I., R.A.G., G.P., V.C.B.). *R.J. Lederman and V.C. Babaliaros contributed equally. Search for more papers by this author Originally published23 May 2022https://doi.org/10.1161/CIRCINTERVENTIONS.122.012106Circulation: Cardiovascular Interventions. 2022;15Footnotes*R.J. Lederman and V.C. Babaliaros contributed equally.For Sources of Funding and Disclosures, see page 552.Correspondence to: Adam B. Greenbaum, MD, Emory Structural Heart and Valve Center, 550 Peachtree St NE, 4th Floor, Davis-Fischer Bldg, Atlanta, GA 30308. Email adam.b.[email protected]edu

0238 Perceived Childhood Neighborhood Safety and Sleep Health during Adulthood

Abstract Introduction Neighborhood safety has been cross-sectionally associated with sleep health at different life stages. However, few studies have investigated childhood neighborhood safety and adulthood sleep despite the possibility that childhood neighborhood safety may serve as a modifiable target for primordial prevention of poor sleep health. Methods Using data from 1,611 Black/African-American women enrolled in the Study of Environment, Lifestyle and Fibroids, we investigated associations between perceived childhood neighborhood safety and adulthood sleep. Participants reported safety of their childhood neighborhoods as unsafe vs. safe at ages 5,10, and 15 years. Participants also self-reported current (ages 23-35 years) sleep duration and quality (i.e., frequently wake feeling unrested [≥4 days/week] and frequent insomnia symptoms [≥15 days/month of difficulty falling or staying asleep]). Adjusting for childhood socioeconomic characteristics, log binomial models estimated prevalence ratios (PRs) and 95% confidence intervals (CIs). For perceived safety at ages 10 and 15 years, we applied inverse probability weights to models to adjust for perceived neighborhood safety at prior ages. Results Mean age ± standard deviation was 29 ± 3.5 years. Prevalence of residence in a childhood neighborhood perceived as unsafe increased with age (Age 5- 20%, Age 10- 22%, Age 15- 31%), and 17% reported an unsafe neighborhood at every age. Both short sleep duration (&amp;lt;7 hours) and frequently waking feeling unrested during adulthood were reported by approximately 60% of women, and 10% reported frequent insomnia symptoms. Participants in perceived unsafe vs. safe neighborhoods at every age were more likely to frequently wake feeling unrested as adults (PR=1.12 [95% CI: 1.00-1.25]). Perceived unsafe neighborhood at ages 5 and 15 years was associated with frequent insomnia symptoms and frequently waking feeling unrested, respectively. Perceived unsafe neighborhood at age 10 years was marginally associated with a higher prevalence of both frequently waking feeling unrested (PR=1.11 [0.98-1.27]) and frequent insomnia symptoms (PR=1.58 [0.99-2.52]) during adulthood. Conclusion Perceived unsafe neighborhood during childhood was associated with poorer sleep during adulthood among a cohort of young Black women. Support (If Any) Division of Intramural Research, National Institutes of Health (NIH), National Institute of Environmental Health Sciences (Z1AES103325[CLJ] and 1ZIAES049013[DB]), and the American Recovery and Reinvestment Act funds designated for NIH research

A Longitudinal Study of COVID-19 Sequelae and Immunity: Baseline Findings.

A substantial proportion of persons who develop COVID-19 report persistent symptoms after acute illness. Various pathophysiologic mechanisms have been implicated in the pathogenesis of postacute sequelae of SARS-CoV-2 infection (PASC). To characterize medical sequelae and persistent symptoms after recovery from COVID-19 in a cohort of disease survivors and controls. Cohort study. (ClinicalTrials.gov: NCT04411147). National Institutes of Health Clinical Center, Bethesda, Maryland. Self-referred adults with laboratory-documented SARS-CoV-2 infection who were at least 6 weeks from symptom onset were enrolled regardless of presence of PASC. A control group comprised persons with no history of COVID-19 or serologic evidence of SARS-CoV-2 infection, recruited regardless of their current health status. Both groups were enrolled over the same period and from the same geographic area. All participants had the same evaluations regardless of presence of symptoms, including physical examination, laboratory tests and questionnaires, cognitive function testing, and cardiopulmonary evaluation. A subset also underwent exploratory immunologic and virologic evaluations. 189 persons with laboratory-documented COVID-19 (12% of whom were hospitalized during acute illness) and 120 antibody-negative control participants were enrolled. At enrollment, symptoms consistent with PASC were reported by 55% of the COVID-19 cohort and 13% of control participants. Increased risk for PASC was noted in women and those with a history of anxiety disorder. Participants with findings meeting the definition of PASC reported lower quality of life on standardized testing. Abnormal findings on physical examination and diagnostic testing were uncommon. Neutralizing antibody levels to spike protein were negative in 27% of the unvaccinated COVID-19 cohort and none of the vaccinated COVID-19 cohort. Exploratory studies found no evidence of persistent viral infection, autoimmunity, or abnormal immune activation in participants with PASC. Most participants with COVID-19 had mild to moderate acute illness that did not require hospitalization. The prevalence of reported PASC was likely overestimated in this cohort because persons with PASC may have been more motivated to enroll. The study did not capture PASC that resolved before enrollment. A high burden of persistent symptoms was observed in persons after COVID-19. Extensive diagnostic evaluation revealed no specific cause of reported symptoms in most cases. Antibody levels were highly variable after COVID-19. Division of Intramural Research, National Institute of Allergy and Infectious Diseases.

IgM anti-ACE2 autoantibodies in severe COVID-19 activate complement and perturb vascular endothelial function.

BackgroundSome clinical features of severe COVID-19 represent blood vessel damage induced by activation of host immune responses initiated by the coronavirus SARS-CoV-2. We hypothesized autoantibodies against angiotensin-converting enzyme 2 (ACE2), the SARS-CoV-2 receptor expressed on vascular endothelium, are generated during COVID-19 and are of mechanistic importance.MethodsIn an opportunity sample of 118 COVID-19 inpatients, autoantibodies recognizing ACE2 were detected by ELISA. Binding properties of anti-ACE2 IgM were analyzed via biolayer interferometry. Effects of anti-ACE2 IgM on complement activation and endothelial function were demonstrated in a tissue-engineered pulmonary microvessel model.ResultsAnti-ACE2 IgM (not IgG) autoantibodies were associated with severe COVID-19 and found in 18/66 (27.2%) patients with severe disease compared with 2/52 (3.8%) of patients with moderate disease (OR 9.38, 95% CI 2.38–42.0; P = 0.0009). Anti-ACE2 IgM autoantibodies were rare (2/50) in non-COVID-19 ventilated patients with acute respiratory distress syndrome. Unexpectedly, ACE2-reactive IgM autoantibodies in COVID-19 did not undergo class-switching to IgG and had apparent KD values of 5.6–21.7 nM, indicating they are T cell independent. Anti-ACE2 IgMs activated complement and initiated complement-binding and functional changes in endothelial cells in microvessels, suggesting they contribute to the angiocentric pathology of COVID-19.ConclusionWe identify anti-ACE2 IgM as a mechanism-based biomarker strongly associated with severe clinical outcomes in SARS-CoV-2 infection, which has therapeutic implications.FUNDINGBill & Melinda Gates Foundation, Gates Philanthropy Partners, Donald B. and Dorothy L. Stabler Foundation, and Jerome L. Greene Foundation; NIH R01 AR073208, R01 AR069569, Institutional Research and Academic Career Development Award (5K12GM123914-03), National Heart, Lung, and Blood Institute R21HL145216, and Division of Intramural Research, National Institute of Allergy and Infectious Diseases; National Science Foundation Graduate Research Fellowship (DGE1746891)

Transcatheter Electrosurgical Laceration and Stabilization of Failed MitraClip[s]/SAPIEN M3 for Treatment of Failed MitraClip.

HomeCirculation: Cardiovascular InterventionsVol. 15, No. 5Transcatheter Electrosurgical Laceration and Stabilization of Failed MitraClip[s]/SAPIEN M3 for Treatment of Failed MitraClip No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessCase ReportRequest AccessFull TextTranscatheter Electrosurgical Laceration and Stabilization of Failed MitraClip[s]/SAPIEN M3 for Treatment of Failed MitraClip Errol K. Inci, Adam B. Greenbaum, Robert J. Lederman, Keshav Kohli, John C. Lisko, Isida Byku, Patrick T. Gleason, Joe X. Xie, Nikoloz Shekiladze and Vasilis C. Babaliaros Errol K. InciErrol K. Inci https://orcid.org/0000-0002-4449-444X Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Adam B. GreenbaumAdam B. Greenbaum https://orcid.org/0000-0001-7496-5954 Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Robert J. LedermanRobert J. Lederman https://orcid.org/0000-0003-1202-6673 Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (R.J.L.). Search for more papers by this author , Keshav KohliKeshav Kohli https://orcid.org/0000-0002-1469-4088 Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Atlanta (K.K.). Search for more papers by this author , John C. LiskoJohn C. Lisko Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Isida BykuIsida Byku Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Patrick T. GleasonPatrick T. Gleason https://orcid.org/0000-0001-5739-9030 Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Joe X. XieJoe X. Xie Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author , Nikoloz ShekiladzeNikoloz Shekiladze Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author and Vasilis C. BabaliarosVasilis C. Babaliaros Correspondence to: Vasilis Babaliaros, MD, Emory Structural Heart and Valve Center, 550 Peachtree St NE, 4th Floor Davis-Fischer Bldg, Atlanta, GA 30308. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9438-0846 Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA (E.K.I., A.B.G., J.C.L., I.B., P.T.G., J.X.X., N.S., V.C.B.). Search for more papers by this author Originally published17 May 2022https://doi.org/10.1161/CIRCINTERVENTIONS.122.012014Circulation: Cardiovascular Interventions. 2022;15FootnotesFor Sources of Funding and Disclosures, see page 457.Correspondence to: Vasilis Babaliaros, MD, Emory Structural Heart and Valve Center, 550 Peachtree St NE, 4th Floor Davis-Fischer Bldg, Atlanta, GA 30308. Email [email protected]edu