Cardiovascular Magnetic Resonance in Cardiac Amyloidosis: Part I-Technical Foundations, Techniques, and Endpoints.

Abstract Extracellular vesicles (EVs) are emerging as promising acellular nanotherapeutics for musculoskeletal repair. Matrix vesicles, a matrix-bound subset of EVs, are essential mediators of endochondral ossification (EO) in bone development and fracture repair. This study aims to design bioengineered matrix vesicles from hypertrophic cartilage microtissues to drive EO for bone repair. Human mesenchymal stromal cell (hBMSC) microtissues were differentiated with/without BMP2 in chondrogenic or hypertrophic medium. Isolated matrix vesicles were characterized for physiochemical properties and biological functionality. BMP2 and hypertrophic conditioning significantly increased vesicle yield (1.5-fold), alkaline phosphatase activity (3.24-fold), calcium-binding capacity (8.82-fold), and growth factor content (BMP2, VEGF). These vesicles promoted hBMSCs proliferation, migration, and mineralization and enhanced angiogenesis in human endothelial colony forming cells, with BMP2 and hypertrophically conditioned vesicles showing the most pronounced effects. Proteomics analysis confirmed the enrichment of proteins involved in extracellular matrix remodelling, mineral deposition and vascularization within these hypertrophically engineered vesicles. These findings demonstrate that hypertrophic induction of cartilaginous microtissues substantially improves the yield and therapeutic potential of matrix vesicles. Taken together, this research unveils a powerful strategy to bioengineer developmentally inspired vesicles that not only recapitulate key cues of EO but offers a tailorable, multifunctional nanotherapeutic platform for improved bone regeneration strategies.

Amyloidosis is a rare, heterogeneous condition characterized by extracellular deposition of misfolded protein fibrils, resulting in organ dysfunction. Gastrointestinal amyloidosis (GIA), an uncommon manifestation, is often underdiagnosed due to its nonspecific symptoms, such as weight loss, abdominal pain, and diarrhea. Early recognition and accurate amyloid typing are crucial, as treatment strategies depend on the specific subtype involved. We report a case of a 42-year-old African male presenting with chronic epigastric pain, significant weight loss (BMI: 17.1), and a history of GERD. He had recently traveled to Equatorial Guinea. His symptoms, including nausea, decreased appetite, constipation, and persistent epigastric pain, were unresponsive to proton pump inhibitors. On examination, he was hypotensive and tachycardic. Laboratory workup revealed hyponatremia and elevated troponin T. Imaging showed fecal impaction and pyloric edema. Upper endoscopy and colonoscopy with biopsies confirmed amyloid deposition in the stomach, duodenum, ileum, and colon. Congo red staining demonstrated classic apple-green birefringence under polarized light. Cardiac evaluation revealed reduced global longitudinal strain. Serum studies showed elevated free lambda light chains and an IgG-lambda monoclonal band, while the urine protein/creatinine ratio was 361 mg/g, consistent with proteinuria. Chronic hepatitis B infection with detectable HBV DNA and elevated gamma/delta T cells on the lymphoma panel raised concerns for an underlying T-cell lymphoproliferative disorder. This case highlights the diagnostic complexity of gastrointestinal amyloidosis with multisystem involvement. The patient’s presentation, along with elevated free light chains and monoclonal gammopathy, raised suspicion for AL amyloidosis, though chronic hepatitis B and possible lymphoproliferative disease kept AA amyloidosis in the differential. Consistent with the literature, vague gastrointestinal (GI) symptoms often delay diagnosis, underscoring the role of Congo red staining and mass spectrometry for confirmation and subtype identification. Recent trials support daratumumab for AL and patisiran/inotersen for ATTR amyloidosis. Early, accurate diagnosis is key to initiating appropriate therapy and improving outcomes, with multidisciplinary involvement crucial for optimal care.

Background Amyloid transthyretin cardiomyopathy (ATTR-CM) results from extracellular deposition of misfolded transthyretin (TTR), causing progressive heart failure. Naturally-occurring antibodies (nAbs) targeting misfolded proteins exist in neurodegenerative disease, but their presence in ATTR-CM is unknown. The objective of this study is to determine whether nAbs against TTR (nAbsTTR) exist in humans and whether they are influenced by disease or its treatment. Methods Serum from healthy donors, umbilical cord blood (UCB), and patients with ATTR-CM - both untreated and receiving TTR-stabilizing therapy - was analyzed for nAbsTTR using immunoassays, blotting, and binding studies. Functional activity was evaluated in a fibril formation assay. Results nAbsTTR binding both native and amyloid TTR (ATTR) with high affinity (KD 30 nM/7 nM) were detected in healthy serum and UCB. NAbsTTR levels were significantly altered in ATTR-CM compared to controls: nAbsTTR (IgG) were higher while nAbsTTR (IgM) were lower. nAbsTTR of both subtypes significantly increased by 22% (p ≤ 0.05) in patients receiving TTR-stabilizing therapy. In vitro, nAbsTTR suppressed TTR fibril aggregation. Conclusions Naturally-occurring TTR-targeting antibodies are present from birth, modulated by disease and therapy, and inhibit fibril formation. These findings reveal an unrecognized immune mechanism with potential relevance for ATTR-CM pathogenesis and treatment.

Multidimensional care in transthyretin cardiac amyloidosis: Integrating extracardiac organ involvement and comorbidity management.

Localized amyloidosis of the upper aerodigestive tract is an uncommon and benign condition characterized by extracellular amyloid deposition. While the larynx is the most frequently involved site, progressive, multifocal mucosal involvement remains exceedingly rare. We report the case of a 58-year-old male initially diagnosed with localized laryngeal amyloidosis confirmed via Congo red staining. The initial laryngeal lesions were excised using conservative endoscopic surgery to both confirm the diagnosis and alleviate symptoms. However, no additional treatment was recommended by the rheumatology department since the patient's further evaluations did not indicate a diagnosis of systemic amyloidosis. Over an 11-year follow-up period, sequential progression to the nasopharynx was observed after five years and to the nasal cavity after 11 years. The patient remained free of systemic involvement throughout, confirmed by comprehensive evaluations including serum and urine immunofixation, renal and hepatic panels, and 24-hour urine analysis. Symptomatic relief was achieved with a series of conservative surgical interventions addressing airway and auditory symptoms. The patient remains under active surveillance. This case highlights a rare, progressive pattern of localized amyloidosis involving contiguous mucosal sites in the upper aerodigestive tract. It underscores the importance of long-term follow-up, systematic evaluation to exclude systemic disease, and the efficacy of conservative surgical management. To our knowledge, this is the first reported case of progressive, segmental spread of localized amyloidosis involving the larynx, the nasopharynx, and the nasal cavity over more than a decade.

The blood‑retinal barrier (BRB), a critical component of the retinal neurovascular unit (NVU), is essential for maintaining retinal homeostasis. Dysfunction of the BRB contributes to vascular leakage, neuronal degeneration and gliosis, which are the core pathological hallmarks of diabetic retinopathy (DR) and retinal vein occlusion (RVO). Despite the importance of the BRB, the molecular mechanisms underlying the preservation of BRB integrity under pathological conditions remain unclear. The present study identified the endothelial receptor unc‑5 netrin receptor B (UNC5B) as a critical regulator of BRB and NVU homeostasis and a potential therapeutic target for neurovascular protection. Analysis of a public Gene Expression Omnibus single‑cell transcriptomic dataset, cell and animal models, and clinical samples revealed reduced UNC5B expression in the aqueous humor of patients and in the retinas of DR and RVO models. In vitro, endothelial knockdown of UNC5B increased apoptosis (assessed by PI/calcein‑AM staining), impaired barrier function (evaluated by BSA uptake and permeability of cell monolayer) and reduced pericyte recruitment, whereas UNC5B knockdown in pericytes had no detectable effects on pericyte proliferation, apoptosis or migration. In vivo, endothelial‑specific UNC5B deficiency markedly exacerbated retinal vascular leakage and structural damage in the DR model, as evidenced by Evans blue leakage, Periodic acid‑Schiff staining and immunofluorescence analyses. Furthermore, UNC5B knockdown abolished the protective effects of high‑dose netrin‑1 administration in DR mice. Endothelial UNC5B modulation, including knockdown and overexpression, affected not only the vascular integrity but also the neural components within the NVU, as evidenced by altered retinal ganglion cell degeneration and glial activation in the DR model, assessed using NeuN, β‑III tubulin and vimentin staining. In the RVO model, endothelial UNC5B deficiency aggravated retinal edema and thinning, as revealed by in vivo retinal imaging. Mechanistically, transcriptomic and protein analyses revealed that UNC5B downregulation was associated with increased extracellular matrix protein deposition and reduced Hippo pathway activity. Collectively, these findings established UNC5B as a key mediator of BRB and NVU stability, and highlighted its therapeutic potential in maintaining vascular integrity and protecting neural elements in retinal vascular diseases.

Proteinopathies play a complex interplay in the pathogenesis of multifactorial neurological disorders. In Alzheimer's disease (AD), the extracellular deposition of amyloid-β (Aβ) plaques and intracellular accumulation of hyperphosphorylated tau into neurofibrillary tangles are the two principal pathological hallmarks. In both cases, nucleation-dependent self-assembly triggers fibril formation and consequent aggregation that disrupts synaptic integrity and accelerates neuronal degeneration. The emerging interconnection between both the proteinopathies, wherein Aβ oligomers promote tau hyperphosphorylation and subsequent aggregation, highlights the need for developing multifunctional dual Aβ-tau aggregation inhibitors. Over the past decade, several dual-acting small molecules have been reported, including synthetic scaffolds (sulfonamides, thiophenes, acridones, isoquinolinium analogues), semi-synthetic derivatives (curcumin, tacrine, ferulic acid), and naturally derived compounds (neferine, pyrogallol, chrysin). While these molecules demonstrate promising in vitro inhibition of both Aβ and tau aggregation through the disruption of β-sheet formation and, in some cases, disaggregation of preformed fibrils; however, their translational potential is often constrained by suboptimal brain penetration, moderate potency, or limited correlation between aggregation inhibition and neuroprotection. This review provides comprehensive molecular mechanisms of Aβ and tau aggregation and a detailed structure-activity relationships (SAR) of reported dual inhibitors to guide the rational design of future novel multitarget therapeutics with improved drug-likeness and disease-modifying potential for AD.

Pressure wounds of the skin are common but challenging complications after spinal cord injury (SCI). Due to altered circulation, reduced macrophage recruitment, and compromised immunity at early time points, skin wound healing is impaired in SCI patients. To promote macrophage recruitment, topical elastin-like polypeptides (ELP) fused with α-melanocyte-stimulating hormone (MSH-ELP) and monocyte chemoattractant protein-1 (MCP-ELP) were developed. Constructs encoding MSH-ELP or MCP-ELP in a pET25b+ vector were transformed into E. coli for expression. Physical and biological in vitro assays were conducted to ensure that the fusion proteins exhibited the expected bioactivity; subsequently, they were tested as topical treatments on experimental skin wounds on SCI mice. SDS-PAGE and western blot analysis confirmed single bands with molecular weights of 26.3kDa (MSH-ELP) and 33.4kDa (MCP-ELP), respectively, forming nanoparticles of 100-250nm in diameter at the tested concentrations, with a lack of toxicity. MSH-ELP reduced lipopolysaccharide-induced inflammation and enhanced the chemotactic response of THP-1 cells. In experimental skin wounds on SCI mice, the nanoparticles enhanced the recruitment of macrophages in a time-dependent manner. We also observed a reduction in scar area and wound width, together with increased macrophage (M2) activity, increased angiogenesis, and extracellular matrix protein deposition in the wound area. In conclusion, we developed a nanoparticle system that demonstrates superior chemotactic response relative to its native form, maintains a safe biocompatibility profile, and significantly improves cutaneous wound healing in an SCI mouse model.

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in elderly individuals for which no effective treatments are currently available. The photoreceptor loss in dry AMD is secondary to the demise of the retinal pigment epithelium (RPE) cells. The accumulation of extracellular deposits, known as drusen, resulting in part from deficient lysosomal and autophagosomal degradation, is a key feature of dry AMD pathogenesis. Chaperone-mediated autophagy (CMA) is a selective lysosomal degradation pathway that maintains proteostasis by targeting specific cytosolic proteins for lysosomal translocation and degradation. LAMP2A (lysosome-associated membrane protein 2A) functions as the key lysosomal receptor required for CMA. Using Lamp2a knockout mouse, we show that selective CMA dysfunction recapitulates AMD-like pathologies, including sub-RPE lipid and protein deposits, RPE atrophy, Bruch's membrane thickening, and impaired autophagic activity. Furthermore, we identify large-conductance Ca²⁺-activated K⁺ (BK) channels as a therapeutic target for restoring autophagic activity. Mechanistically, pharmacological activation of BK channels with the small-molecule agonist GLA-1-1 enhances macroautophagy and stimulates autophagic flux by promoting autophagosome-lysosome fusion. Importantly, oral administration of GLA-1-1 in markedly attenuates structural, functional, and molecular retinal abnormalities in Lamp2a -deficient mice, suggesting that pharmacological activation of macroautophagy through facilitating autophagosome-lysosome fusion can partially compensate for CMA deficiency. Together, these findings demonstrate that pharmacological activation of macroautophagy can ameliorate the retinal phenotype resulting from CMA dysfunction and support BK channel activation by GLA-1-1 as a promising therapeutic strategy for dry AMD.

Alzheimer's disease (AD) is the most prevalent cause of dementia and can be conceptualized as a tauopathy initiated by the accumulation of amyloid-β (Aβ) in the brain. The clinical introduction of anti-Aβ antibody therapies has marked the beginning of a new era in disease-modifying treatment for dementia. While the deleterious effects of Aβ on postsynaptic spines and axonal microtubules have been increasingly clarified, recent studies have shifted attention beyond extracellular Aβ deposition as senile plaques to the pathogenic significance of intracellular Aβ. In particular, accumulating evidence highlights lysosomes as critical sites of intracellular Aβ toxicity. Interactions between Aβ and gangliosides, v-ATPase-dependent lysosomal acidification, and lysosomal membrane integrity are the key determinants of disease progression. In parallel, additional molecular players, including components of the complement cascade and asparaginyl endopeptidase, have been implicated in linking Aβ pathology to tau dysregulation and neurodegeneration. As therapeutic strategies targeting Aβ enter clinical practice, these emerging pathways represent promising targets for the next generation of AD treatment. Here, we summarize current insights and ongoing therapeutic developments centered on these mechanisms.

Transthyretin amyloidosis (ATTR) is a progressive multisystem disorder characterized by extracellular deposition of misfolded transthyretin fibrils, leading to neurological, cardiac, gastrointestinal, urogenital, sexual, and ophthalmological involvement. While disease-modifying therapies have significantly improved survival and slowed disease progression, a substantial proportion of patients continue to experience a high symptomatic burden that markedly impairs quality of life. Symptomatic manifestations often occur early, may precede the diagnosis, and frequently persist despite etiological treatment. This review provides a comprehensive overview of the symptomatic management of ATTR, with particular emphasis on autonomic dysfunction and its systemic consequences. We discuss current therapeutic strategies for orthostatic hypotension, gastrointestinal dysmotility, nutritional impairment, sexual dysfunction, lower urinary tract dysfunction, and ophthalmological involvement, highlighting both pharmacological and non-pharmacological approaches. Special attention is given to treatment limitations related to cardiac involvement, autonomic failure, and drug tolerability. Despite the clinical relevance of symptom control in ATTR, evidence-based recommendations remain scarce, and no dedicated guidelines currently exist. Most therapeutic approaches are derived from observational studies, expert opinion, and clinical experience. Improved awareness of symptomatic manifestations, early intervention, and a multidisciplinary, individualized approach are essential to optimize patient outcomes. Future research should focus on prospective studies and the development of structured symptomatic treatment algorithms to complement disease-modifying therapies and enhance patient-centered care in ATTR.

Potassium channel dysfunction and altered neuronal excitability potentially contribute to cognitive decline in amyloid-β (Aβ) pathology. In particular, the accumulation of intracellular Aβ, preceding extracellular plaque deposition, has been implicated in dysregulated excitability and early-stage neuronal stress. However, the molecular mechanisms linking intracellular Aβ to altered neuronal excitability remain incompletely understood. This study aimed to identify a mediator of intracellular Aβ toxicity contributing to neuronal dysfunction in Aβ pathology. We performed a genome-wide human protein chip assay, followed by in vitro binding assays, surface plasmon resonance, and in vivo colocalization analysis using postmortem Alzheimer’s disease (AD) brain tissues in which Aβ pathology is observed. We generated neuronal cell lines stably expressing mRFP-Aβ to model intracellular Aβ accumulation and investigate its pathogenic effects. In addition, we evaluated potassium channel activity and neurotoxicity in Aβ-treated neuronal cells and assessed neuronal excitability and cognitive functions in APPNL−G−F knock-in mice using electrophysiological recordings and behavioral tests. Voltage-gated potassium channel β2 (Kvβ2) was identified as a novel intracellular Aβ-binding protein. Aβ directly bound to the N-terminus of Kvβ2, disrupting its interaction with EB1 and impairing Kv1-Kvβ2 localization to the axon initial segment. In neuronal cell lines expressing intracellular mRFP-Aβ, Kvβ2 colocalized with Aβ in the cytosol, and Kv1 trafficking to the plasma membrane was markedly reduced. Consistent with this observation, colocalization of Aβ and Kvβ2 was confirmed in the brains of AD patients. In addition, enforced expression of Kvβ2, but not Aβ-binding-defective Kvβ2 ∆(2–18) mutant, rescued potassium channel dysfunction and suppressed neurotoxicity in Aβ-treated neuronal cells. Furthermore, lentiviral delivery of Kvβ2 into APPNL−G−F mice reduced neuronal hyperexcitability, rescued activity-related neuronal markers, and ameliorated memory deficits, whereas the Kvβ2 ∆(2–18) mutant did not. These findings suggest that the interaction between Kvβ2 and Aβ mediates neuronal hyperexcitability and memory impairment in APPNL−G−F mice, elucidating a potential mechanism underlying Kv1 channel dysfunction in Aβ pathology.

Background:Transthyretin cardiac amyloidosis (ATTR-CA) results from the extracellular deposition of misfolded transthyretin (mis-TTR) and promotes progressive cardiac dysfunction. Current therapies, such as stabilizers and silencers, reduce further fibril accumulation but fail to clear existing deposits. Monoclonal antibodies (mAbs) targeting mis-TTR have emerged as promising disease-modifying agents, supported by recent observations of circulating anti-TTR antibodies in patients who exhibited spontaneous clinical improvement.Methods:This study aimed to purify natural anti-TTR antibodies from two ATTR-CA patients and compare the respective binding properties to those of a previously described therapeutic anti-TTR mAb fragment (Ab-A F(ab')2). Statistical significance was determined using Student's t-test.Results:Both natural antibodies and the Ab-A F(ab')2 demonstrated high-affinity binding to misfolded TTR (n = 3), while the competition assays revealed dose-dependent inhibition, indicating shared epitope recognition.Conclusions:These findings provide translational evidence that therapeutic anti-TTR mAbs may mimic naturally protective antibodies, suggesting that these antibodies could promote amyloid clearance and deliver true disease-modifying benefits in ATTR-CA.

ABSTRACT Age‐related macular degeneration (AMD) is a global vision threatening disease affecting the macular region of the retina. AMD is classified into two forms: dry and wet AMD. There are no effective treatment options available for dry AMD (80% of cases). The cellular pathology includes oxidative stress and dysfunctional autophagy challenging the homeostasis of the retinal pigment epithelial (RPE) cells. Clinical findings include the formation of drusen deposits beneath the RPE cells consisting of 42 amino acids long amyloid beta (Aβ) among other components. However, the origin of drusen remains elusive. The 5xFAD (familiar Alzheimer's disease) mouse model of Alzheimer's disease produces abundant levels of Aβ making it an interesting model to study the possible relationship of Aβ to the formation of extracellular deposits and AMD‐like pathology. An immunohistology analysis of the 5xFAD mouse model showed accumulation of autophagic markers SQSTM1 (sequestosome 1) and ubiquitin in the RPE. Concurrently, the markers of secretory autophagy enabling the delivery of the intracellular material to the extracellular lumen were upregulated. Aβ, SQSTM1, ubiquitin, catalase, and TRIM16 (tripartite motif containing 16) shifted age‐dependently from intracellular origin to drusen‐like deposits beneath the RPE cells. Additionally, classical proteins secreted via secretory autophagy, IL‐1β (interleukin 1β), HMGB1 (high mobility group box‐1), and ferritin showed similar accumulation which became visible in fundus age‐dependently. These findings suggest a role for Aβ in the cellular pathogenesis of AMD. Furthermore, this model showed activated secretory autophagy pathway suggesting a role for Aβ in drusen‐like deposition formation.

Staining techniques play a crucial role in oral pathology by enabling the visualization and identification of specific cellular and tissue components that are not readily discernible with routine hematoxylin and eosin (H&E) staining. Special stains utilize selective chemical interactions between dyes and tissue components to improve diagnostic accuracy by selectively highlighting carbohydrates, lipids, proteins, mucins, microorganisms, connective tissue fibers, pigments, and other structural elements. These stains functions through various mechanisms, including acid–base interactions, oxidation–reduction reactions, and mordant-mediated binding. Common examples include Periodic Acid–Schiff (PAS) for glycogen and fungal organisms, Alcian Blue for acidic mucins, Congo Red for amyloid deposits, and silver-based stains for melanin, reticulin, and microorganisms. In oral pathology, special stains are indispensable for detecting infectious agents, differentiating tumor types, identifying abnormal extracellular deposits, and evaluating structural tissue alterations. Key Words: Congo red, Hematoxylin and Eosin, Masson’s Trichrome stain, Periodic Acid–Schiff, Special stains

Introduction Cardiac amyloidosis (CA) is a progressive and often terminal infiltrative cardiomyopathy resulting from the extracellular deposition of misfolded protein fibrils—primarily immunoglobulin light chains (AL) or transthyretin (ATTR)—within the heart muscle. While historically perceived as a rare condition affecting the elderly, advances in non-invasive imaging have revealed CA as an underdiagnosed cause of heart failure. However, its manifestation in young adults remains exceptionally rare, presenting a significant diagnostic challenge for general practitioners. Early recognition is vital, as subtype-specific therapies can significantly alter the clinical trajectory. Case Illustration We report the case of a 22-year-old male who presented with a two-week history of progressive dyspnea, orthopnea, abdominal distention, and periorbital edema. Physical examination revealed signs of systemic congestion, including ascites (shifting dullness) and decreased breath sounds in the right lung, alongside a blood pressure of 130/90 mmHg and a heart rate of 94 bpm . Laboratory findings were remarkable for a severely elevated NT-proBNP of 8177.11 pg/mL and a high hemoglobin of 18.2 g/dL . Chest radiography demonstrated cardiomegaly (CTR 63%), pulmonary edema, and bilateral pleural effusion. Electrocardiography (ECG) revealed low-voltage QRS complexes, which stood in stark contrast to the echocardiographic evidence of significant ventricular wall thickening (IV S 1.27 cm, LV PW 1.83 cm, ) and a reduced ejection fraction of 35.3% . The discordance between ECG voltage and echocardiographic mass, combined with Grade III diastolic dysfunction, strongly suggested cardiac amyloidosis. Discussion The diagnostic hallmark in this case is the "voltage-to-mass" discordance, a pathognomonic red flag where amyloid fibrils insulate the myocardium, dampening electrical signals despite increased wall thickness. In a 22-year-old, the differential diagnosis includes hereditary transthyretin amyloidosis (vATTR) or immunoglobulin light chain (AL) amyloidosis, alongside mimickers like sarcoidosis or Fabry disease. The elevated NT-proBNP and high hemoglobin reflect severe hemodynamic stress and potential hemoconcentration. Management involved stabilizing heart failure using loop diuretics and transitioning to guideline-directed medical therapy (GDMT), while pursuing definitive subtyping through serum/urine immunofixation and cardiac imaging. Conclusion This case emphasizes that cardiac amyloidosis must be considered in young patients presenting with unexplained heart failure and restrictive physiology. Maintaining a high index of suspicion for "red flags" like ECG-echo discordance is essential to facilitate early diagnosis and initiation of life-saving, subtype-specific treatments.

Machine learning for site risk prediction in clinical trials: development, external validation, and operational application in site qualification.

Abstract Background/Introduction In amyloidosis, a misfolding of proteins is followed by extracellular deposition of fibrils, with the consequence of organ dysfunction. Cardiac deposition results in a restrictive cardiomyopathy with increased myocardial stiffness. Transthyretin amyloidosis (ATTR) can either be age-related (ATTR wild-type; ATTRwt), or genetically determined (ATTR variant; ATTRv) (Merlini and Westermark 2004), which is inherited in an autosomal dominant manner. Detecting symptom onset in ATTRv carriers is crucial to initiate appropriate treatment. Novel ultrasound-based cardiac elastography allows for non-invasive quantification of myocardial stiffness. Time Harmonic Ultrasound elastography (THE) based on portable vibration pillows and conventional ultrasound, recently showed the capacity to detect increased myocardial stiffness in cardiac ATTRwt Amyloidosis (Meyer, Wellge et altera 2025). Purpose We examined asymptomatic ATTRv carriers using THE to investigate the potential of early, stiffness-based detection of cardiac dysfunction. Methods 19 healthy volunteers (10 women, age range 19-88 years) and 14 ATTRv carriers (8 woman, age range 33-79years) were examined with standard echocardiography and measured with THE. In the ATTRv group a bone scintigraphy and biomarker testing was added according to ESC recommendations (Garcia-Pavia, Rapezzi et altera 2021). For THE, harmonic multifrequency vibrations (60,70, 80 Hz) were induced by a custom-built vibration pillow (Elastance Imaging, Columbus, Ohio, US) placed underneath the thorax (see Figure 1). Data were acquired in parasternal long axis view in breath hold (15 cm penetration depth, 4s acquisition time) with a THE device (GAMPT Merseburg, Germany). Diastolic shear wave speed maps (SWS) were generated using k-MDEV gradient inversion. Manually drawn regions of interest were placed in the septum and the posterior wall. Results All ATTRv carriers showed normal echocardiography data and negative bone scintigraphy (Perugini Grade 0). NTproBNP and Troponin T were in a normal range( NTproBNP mean 57.9ng/l; Troponin T mean 5.8ng/l). SWS was increased in ATTRv patients (septum: 2.0 [1.7-2.5] m/s; posterior wall: 2.2 [1.7-2.5] m/s) compared to healthy controls (septum: 1.6 [1.3-2.5] m/s; posterior wall: 1.9 [1.6-2.3]; both p<0.05) with an area under the curve of 0.9 and 0.75 for the separation of the groups based on septal and posterior wall stiffness respectively. Conclusion We found elevated myocardial stiffness in asymptomatic ATTRv carriers suggesting ATTR Amyloidosis related organ dysfunction prior to subjective symptoms or objective signs measured with standard tools. These results highlight the potential of early stiffness-based detection of myocardial dysfunction and may initiate a re-evaluation of the current amyloidosis work-up and the time to start a specific therapy.THE Setup Comparison ATTRv versus healthy controls

Alzheimer’s disease (AD) is characterised by the intraneuronal aggregation of phosphorylated Tau (pTau) into neurofibrillary tangles and by the extracellular deposition of β-amyloid (Aβ). Tau pathology restricted to the medio-temporal lobe is frequently observed in the elderly brain in the absence of any Aβ deposition and considered as “primary age-related tauopathy” (PART). Here, we applied an unbiased proteomic approach to determine if and how concomitant Aβ pathology modifies the neurofibrillary tangle proteome. Neurofibrillary tangles were isolated by laser capture microdissection from hippocampal sections of 17 post-mortem brains spanning three groups: PART (n = 5; A0, B1–2, C0 scores), intermediate AD (n = 6; A1–2, B2–3, C1–2 scores) and advanced AD (n = 6; A3, B3, C3 scores). Mass spectrometry identified a conserved core of 63 proteins enriched in tangles across all groups, associated with RNA binding. Group-specific signatures were also observed: 33 proteins were significantly enriched only in tangles collected from PART cases and were predominantly linked to structural activity, whereas Aβ-positive cases showed specific enrichment of RNA binding and translation pathways – with intermediate AD cases displaying a transitional profile. Our findings are consistent with PART having distinct tangle proteomic features that could precede Aβ-driven changes; however, the majority of its proteomic signature is in common with tangles within the AD continuum. By addressing how Aβ accumulation alters the tangle proteome, this study provides mechanistic insights into the expansion of Tau pathology, paving the way towards the identification of biomarkers and therapeutic strategies that would allow for stabilisation of Tau pathology in the elderly.