Skip to main content
Top
Published in: Malaria Journal 1/2014

Open Access 01-12-2014 | Research

Global and local genetic diversity at two microsatellite loci in Plasmodium vivax parasites from Asia, Africa and South America

Authors: Mette L Schousboe, Samir Ranjitkar, Rupika S Rajakaruna, Priyanie H Amerasinghe, Flemming Konradsen, Francisco Morales, Rosalynn Ord, Richard Pearce, Toby Leslie, Mark Rowland, Nahla Gadalla, Ib C Bygbjerg, Michael Alifrangis, Cally Roper

Published in: Malaria Journal | Issue 1/2014

Login to get access

Abstract

Background

Even though Plasmodium vivax has the widest worldwide distribution of the human malaria species and imposes a serious impact on global public health, the investigation of genetic diversity in this species has been limited in comparison to Plasmodium falciparum. Markers of genetic diversity are vital to the evaluation of drug and vaccine efficacy, tracking of P. vivax outbreaks, and assessing geographical differentiation between parasite populations.

Methods

The genetic diversity of eight P. vivax populations (n = 543) was investigated by using two microsatellites (MS), m1501 and m3502, chosen because of their seven and eight base-pair (bp) repeat lengths, respectively. These were compared with published data of the same loci from six other P. vivax populations.

Results

In total, 1,440 P. vivax samples from 14 countries on three continents were compared. There was highest heterozygosity within Asian populations, where expected heterozygosity (He) was 0.92-0.98, and alleles with a high repeat number were more common. Pairwise FST revealed significant differentiation between most P. vivax populations, with the highest divergence found between Asian and South American populations, yet the majority of the diversity (~89%) was found to exist within rather than between populations.

Conclusions

The MS markers used were informative in both global and local P. vivax population comparisons and their seven and eight bp repeat length facilitated population comparison using data from independent studies. A complex spatial pattern of MS polymorphisms among global P. vivax populations was observed which has potential utility in future epidemiological studies of the P. vivax parasite.
Appendix
Available only for authorised users
Literature
1.
go back to reference Neafsey DE, Galinsky K, Jiang RH, Young L, Sykes SM, Saif S, Gujja S, Goldberg JM, Young S, Zeng Q, Chapman SB, Dash AP, Anvikar AR, Sutton PL, Birren BW, Escalante AA, Barnwell JW, Carlton JM: The malaria parasite Plasmodium vivax exhibits greater genetic diversity than Plasmodium falciparum. Nat Genet. 2012, 44: 1046-1050.PubMedCentralCrossRefPubMed Neafsey DE, Galinsky K, Jiang RH, Young L, Sykes SM, Saif S, Gujja S, Goldberg JM, Young S, Zeng Q, Chapman SB, Dash AP, Anvikar AR, Sutton PL, Birren BW, Escalante AA, Barnwell JW, Carlton JM: The malaria parasite Plasmodium vivax exhibits greater genetic diversity than Plasmodium falciparum. Nat Genet. 2012, 44: 1046-1050.PubMedCentralCrossRefPubMed
2.
go back to reference Beg MA, Khan R, Baig SM, Gulzar Z, Hussain R, Smego RA: Cerebral involvement in benign tertian malaria. Am J Trop Med Hyg. 2002, 67: 230-232.PubMed Beg MA, Khan R, Baig SM, Gulzar Z, Hussain R, Smego RA: Cerebral involvement in benign tertian malaria. Am J Trop Med Hyg. 2002, 67: 230-232.PubMed
3.
go back to reference Genton B, D’Acremont V, Rare L, Baea K, Reeder JC, Alpers MP, Müller I: Plasmodium vivax and mixed infections are associated with severe malaria in children: a prospective cohort study from Papua New Guinea. PLoS Med. 2008, 5: e127-PubMedCentralCrossRefPubMed Genton B, D’Acremont V, Rare L, Baea K, Reeder JC, Alpers MP, Müller I: Plasmodium vivax and mixed infections are associated with severe malaria in children: a prospective cohort study from Papua New Guinea. PLoS Med. 2008, 5: e127-PubMedCentralCrossRefPubMed
4.
go back to reference Singh H, Parakh A, Basu S, Rath B: Plasmodium vivax malaria: is it actually benign?. J Infect Public Health. 2011, 4: 91-95.CrossRefPubMed Singh H, Parakh A, Basu S, Rath B: Plasmodium vivax malaria: is it actually benign?. J Infect Public Health. 2011, 4: 91-95.CrossRefPubMed
5.
go back to reference Tjitra E, Anstey NM, Sugiarto P, Warikar N, Kenangalem E, Karyana M, Lampah DA, Price RN: Multidrug-resistant Plasmodium vivax associated with severe and fatal malaria: a prospective study in Papua, Indonesia. PLoS Med. 2008, 5: e128-PubMedCentralCrossRefPubMed Tjitra E, Anstey NM, Sugiarto P, Warikar N, Kenangalem E, Karyana M, Lampah DA, Price RN: Multidrug-resistant Plasmodium vivax associated with severe and fatal malaria: a prospective study in Papua, Indonesia. PLoS Med. 2008, 5: e128-PubMedCentralCrossRefPubMed
6.
go back to reference Honma H, Kim JY, Palacpac NM, Mita T, Lee W, Horii T, Tanabe K: Recent increase of genetic diversity in Plasmodium vivax population in the Republic of Korea. Malar J. 2011, 10: 257-PubMedCentralCrossRefPubMed Honma H, Kim JY, Palacpac NM, Mita T, Lee W, Horii T, Tanabe K: Recent increase of genetic diversity in Plasmodium vivax population in the Republic of Korea. Malar J. 2011, 10: 257-PubMedCentralCrossRefPubMed
7.
go back to reference Price RN, Douglas NM, Anstey NM: New developments in Plasmodium vivax malaria: severe disease and the rise of chloroquine resistance. Curr Opin Infect Dis. 2009, 22: 430-435.CrossRefPubMed Price RN, Douglas NM, Anstey NM: New developments in Plasmodium vivax malaria: severe disease and the rise of chloroquine resistance. Curr Opin Infect Dis. 2009, 22: 430-435.CrossRefPubMed
8.
go back to reference Imwong M, Pukrittayakamee S, Renia L, Letourneur F, Charlieu JP, Leartsakulpanich U, Looareesuwan S, White NJ, Snounou G: Novel point mutations in the dihydrofolate reductase gene of Plasmodium vivax: evidence for sequential selection by drug pressure. Antimicrob Agents Chemother. 2003, 47: 1514-1521.PubMedCentralCrossRefPubMed Imwong M, Pukrittayakamee S, Renia L, Letourneur F, Charlieu JP, Leartsakulpanich U, Looareesuwan S, White NJ, Snounou G: Novel point mutations in the dihydrofolate reductase gene of Plasmodium vivax: evidence for sequential selection by drug pressure. Antimicrob Agents Chemother. 2003, 47: 1514-1521.PubMedCentralCrossRefPubMed
9.
go back to reference Cui L, Mascorro CN, Fan Q, Rzomp KA, Khuntirat B, Zhou G, Chen H, Yan G, Sattabongkot J: Genetic diversity and multiple infections of Plasmodium vivax malaria in Western Thailand. Am J Trop Med Hyg. 2003, 68: 613-619.PubMed Cui L, Mascorro CN, Fan Q, Rzomp KA, Khuntirat B, Zhou G, Chen H, Yan G, Sattabongkot J: Genetic diversity and multiple infections of Plasmodium vivax malaria in Western Thailand. Am J Trop Med Hyg. 2003, 68: 613-619.PubMed
10.
go back to reference Schousboe ML, Rajakaruna RS, Amerasinghe PH, Konradsen F, Ord R, Pearce R, Bygbjerg IC, Roper C, Alifrangis M: Analysis of polymorphisms in the merozoite surface protein-3alpha gene and two microsatellite loci in Sri Lankan Plasmodium vivax: evidence of population substructure in Sri Lanka. Am J Trop Med Hyg. 2011, 85: 994-1001.PubMedCentralCrossRefPubMed Schousboe ML, Rajakaruna RS, Amerasinghe PH, Konradsen F, Ord R, Pearce R, Bygbjerg IC, Roper C, Alifrangis M: Analysis of polymorphisms in the merozoite surface protein-3alpha gene and two microsatellite loci in Sri Lankan Plasmodium vivax: evidence of population substructure in Sri Lanka. Am J Trop Med Hyg. 2011, 85: 994-1001.PubMedCentralCrossRefPubMed
11.
go back to reference Kim JR, Imwong M, Nandy A, Chotivanich K, Nontprasert A, Tonomsing N, Maji A, Addy M, Day NP, White NJ, Pukrittayakamee S: Genetic diversity of Plasmodium vivax in Kolkata, India. Malar J. 2006, 5: 71-PubMedCentralCrossRefPubMed Kim JR, Imwong M, Nandy A, Chotivanich K, Nontprasert A, Tonomsing N, Maji A, Addy M, Day NP, White NJ, Pukrittayakamee S: Genetic diversity of Plasmodium vivax in Kolkata, India. Malar J. 2006, 5: 71-PubMedCentralCrossRefPubMed
12.
go back to reference Ord R, Polley S, Tami A, Sutherland CJ: High sequence diversity and evidence of balancing selection in the Pvmsp3alpha gene of Plasmodium vivax in the Venezuelan Amazon. Mol Biochem Parasitol. 2005, 144: 86-93.CrossRefPubMed Ord R, Polley S, Tami A, Sutherland CJ: High sequence diversity and evidence of balancing selection in the Pvmsp3alpha gene of Plasmodium vivax in the Venezuelan Amazon. Mol Biochem Parasitol. 2005, 144: 86-93.CrossRefPubMed
13.
go back to reference Imwong M, Pukrittayakamee S, Gruner AC, Renia L, Letourneur F, Looareesuwan S, White NJ, Snounou G: Practical PCR genotyping protocols for Plasmodium vivax using Pvcs and Pvmsp1. Malar J. 2005, 4: 20-PubMedCentralCrossRefPubMed Imwong M, Pukrittayakamee S, Gruner AC, Renia L, Letourneur F, Looareesuwan S, White NJ, Snounou G: Practical PCR genotyping protocols for Plasmodium vivax using Pvcs and Pvmsp1. Malar J. 2005, 4: 20-PubMedCentralCrossRefPubMed
14.
go back to reference Brito CF, Ferreira MU: Molecular markers and genetic diversity of Plasmodium vivax. Mem Inst Oswaldo Cruz. 2011, 106 (Suppl 1): 12-26.CrossRefPubMed Brito CF, Ferreira MU: Molecular markers and genetic diversity of Plasmodium vivax. Mem Inst Oswaldo Cruz. 2011, 106 (Suppl 1): 12-26.CrossRefPubMed
15.
go back to reference Russell B, Suwanarusk R, Lek-Uthai U: Plasmodium vivax genetic diversity: microsatellite length matters. Trends Parasitol. 2006, 22: 399-401.CrossRefPubMed Russell B, Suwanarusk R, Lek-Uthai U: Plasmodium vivax genetic diversity: microsatellite length matters. Trends Parasitol. 2006, 22: 399-401.CrossRefPubMed
16.
go back to reference Anderson TJ, Su XZ, Bockarie M, Lagog M, Day KP: Twelve microsatellite markers for characterization of Plasmodium falciparum from finger-prick blood samples. Parasitology. 1999, 119 (Pt 2): 113-125.CrossRefPubMed Anderson TJ, Su XZ, Bockarie M, Lagog M, Day KP: Twelve microsatellite markers for characterization of Plasmodium falciparum from finger-prick blood samples. Parasitology. 1999, 119 (Pt 2): 113-125.CrossRefPubMed
17.
go back to reference Imwong M, Nair S, Pukrittayakamee S, Sudimack D, Williams JT, Mayxay M, Newton PN, Kim JR, Nandy A, Osorio L, Carlton JM, White NJ, Day NP, Anderson TJ: Contrasting genetic structure in Plasmodium vivax populations from Asia and South America. Int J Parasitol. 2007, 37: 1013-1022.CrossRefPubMed Imwong M, Nair S, Pukrittayakamee S, Sudimack D, Williams JT, Mayxay M, Newton PN, Kim JR, Nandy A, Osorio L, Carlton JM, White NJ, Day NP, Anderson TJ: Contrasting genetic structure in Plasmodium vivax populations from Asia and South America. Int J Parasitol. 2007, 37: 1013-1022.CrossRefPubMed
18.
go back to reference Koepfli C, Mueller I, Marfurt J, Goroti M, Sie A, Oa O, Genton B, Beck HP, Felger I: Evaluation of Plasmodium vivax genotyping markers for molecular monitoring in clinical trials. J Infect Dis. 2009, 199: 1074-1080.CrossRefPubMed Koepfli C, Mueller I, Marfurt J, Goroti M, Sie A, Oa O, Genton B, Beck HP, Felger I: Evaluation of Plasmodium vivax genotyping markers for molecular monitoring in clinical trials. J Infect Dis. 2009, 199: 1074-1080.CrossRefPubMed
19.
go back to reference Karunaweera ND, Ferreira MU, Munasinghe A, Barnwell JW, Collins WE, King CL, Kawamoto F, Hartl DL, Wirth DF: Extensive microsatellite diversity in the human malaria parasite Plasmodium vivax. Gene. 2008, 410: 105-112.CrossRefPubMed Karunaweera ND, Ferreira MU, Munasinghe A, Barnwell JW, Collins WE, King CL, Kawamoto F, Hartl DL, Wirth DF: Extensive microsatellite diversity in the human malaria parasite Plasmodium vivax. Gene. 2008, 410: 105-112.CrossRefPubMed
20.
go back to reference Gunawardena S, Karunaweera ND, Ferreira MU, Phone-Kyaw M, Pollack RJ, Alifrangis M, Rajakaruna RS, Konradsen F, Amerasinghe PH, Schousboe ML, Galappaththy GN, Abeyasinghe RR, Hartl DL, Wirth DF: Geographic structure of Plasmodium vivax: microsatellite analysis of parasite populations from Sri Lanka, Myanmar, and Ethiopia. Am J Trop Med Hyg. 2010, 82: 235-242.PubMedCentralCrossRefPubMed Gunawardena S, Karunaweera ND, Ferreira MU, Phone-Kyaw M, Pollack RJ, Alifrangis M, Rajakaruna RS, Konradsen F, Amerasinghe PH, Schousboe ML, Galappaththy GN, Abeyasinghe RR, Hartl DL, Wirth DF: Geographic structure of Plasmodium vivax: microsatellite analysis of parasite populations from Sri Lanka, Myanmar, and Ethiopia. Am J Trop Med Hyg. 2010, 82: 235-242.PubMedCentralCrossRefPubMed
21.
go back to reference Ellegren H: Microsatellites: simple sequences with complex evolution. Nat Rev Genet. 2004, 5: 435-445.CrossRefPubMed Ellegren H: Microsatellites: simple sequences with complex evolution. Nat Rev Genet. 2004, 5: 435-445.CrossRefPubMed
22.
go back to reference Imwong M, Sudimack D, Pukrittayakamee S, Osorio L, Carlton JM, Day NP, White NJ, Anderson TJ: Microsatellite variation, repeat array length, and population history of Plasmodium vivax. Mol Biol Evol. 2006, 23: 1016-1018.CrossRefPubMed Imwong M, Sudimack D, Pukrittayakamee S, Osorio L, Carlton JM, Day NP, White NJ, Anderson TJ: Microsatellite variation, repeat array length, and population history of Plasmodium vivax. Mol Biol Evol. 2006, 23: 1016-1018.CrossRefPubMed
23.
go back to reference Ranjitkar S, Schousboe ML, Thomsen TT, Adhikari M, Kapel CM, Bygbjerg IC, Alifrangis M: Prevalence of molecular markers of anti-malarial drug resistance in Plasmodium vivax and Plasmodium falciparum in two districts of Nepal. Malar J. 2011, 10: 75-PubMedCentralCrossRefPubMed Ranjitkar S, Schousboe ML, Thomsen TT, Adhikari M, Kapel CM, Bygbjerg IC, Alifrangis M: Prevalence of molecular markers of anti-malarial drug resistance in Plasmodium vivax and Plasmodium falciparum in two districts of Nepal. Malar J. 2011, 10: 75-PubMedCentralCrossRefPubMed
24.
go back to reference Leslie T, Mayan MI, Hasan MA, Safi MH, Klinkenberg E, Whitty CJ, Rowland M: Sulfadoxine-pyrimethamine, chlorproguanil-dapsone, or chloroquine for the treatment of Plasmodium vivax malaria in Afghanistan and Pakistan: a randomized controlled trial. JAMA. 2007, 297: 2201-2209.CrossRefPubMed Leslie T, Mayan MI, Hasan MA, Safi MH, Klinkenberg E, Whitty CJ, Rowland M: Sulfadoxine-pyrimethamine, chlorproguanil-dapsone, or chloroquine for the treatment of Plasmodium vivax malaria in Afghanistan and Pakistan: a randomized controlled trial. JAMA. 2007, 297: 2201-2209.CrossRefPubMed
25.
go back to reference Leslie T, Mayan I, Mohammed N, Erasmus P, Kolaczinski J, Whitty CJ, Rowland M: A randomised trial of an eight-week, once weekly primaquine regimen to prevent relapse of Plasmodium vivax in Northwest Frontier Province, Pakistan. PLoS One. 2008, 3: e2861-PubMedCentralCrossRefPubMed Leslie T, Mayan I, Mohammed N, Erasmus P, Kolaczinski J, Whitty CJ, Rowland M: A randomised trial of an eight-week, once weekly primaquine regimen to prevent relapse of Plasmodium vivax in Northwest Frontier Province, Pakistan. PLoS One. 2008, 3: e2861-PubMedCentralCrossRefPubMed
26.
go back to reference Ord RL, Tami A, Sutherland CJ: ama1 genes of sympatric Plasmodium vivax and P. falciparum from Venezuela differ significantly in genetic diversity and recombination frequency. PLoS One. 2008, 3: e3366-PubMedCentralCrossRefPubMed Ord RL, Tami A, Sutherland CJ: ama1 genes of sympatric Plasmodium vivax and P. falciparum from Venezuela differ significantly in genetic diversity and recombination frequency. PLoS One. 2008, 3: e3366-PubMedCentralCrossRefPubMed
27.
go back to reference Wooden J, Kyes S, Sibley CH: PCR and strain identification in Plasmodium falciparum. Parasitol Today. 1993, 9: 303-305.CrossRefPubMed Wooden J, Kyes S, Sibley CH: PCR and strain identification in Plasmodium falciparum. Parasitol Today. 1993, 9: 303-305.CrossRefPubMed
28.
go back to reference Pearce RJ, Drakeley C, Chandramohan D, Mosha F, Roper C: Molecular determination of point mutation haplotypes in the dihydrofolate reductase and dihydropteroate synthase of Plasmodium falciparum in three districts of Northern Tanzania. Antimicrob Agents Chemother. 2003, 47: 1347-1354.PubMedCentralCrossRefPubMed Pearce RJ, Drakeley C, Chandramohan D, Mosha F, Roper C: Molecular determination of point mutation haplotypes in the dihydrofolate reductase and dihydropteroate synthase of Plasmodium falciparum in three districts of Northern Tanzania. Antimicrob Agents Chemother. 2003, 47: 1347-1354.PubMedCentralCrossRefPubMed
30.
go back to reference Arlekin: An Integrated Software for Population Genetics Data Analysis. [3.11]. 2012, Ref Type: Computer Program Arlekin: An Integrated Software for Population Genetics Data Analysis. [3.11]. 2012, Ref Type: Computer Program
31.
go back to reference Google: Google Earth. 2014, 24-8-2014. Ref Type: Online Source Google: Google Earth. 2014, 24-8-2014. Ref Type: Online Source
32.
go back to reference Orjuela-Sanchez P, da Silva NS, da Silva-Nunes M, Ferreira MU: Recurrent parasitemias and population dynamics of Plasmodium vivax polymorphisms in rural Amazonia. Am J Trop Med Hyg. 2009, 81: 961-968.CrossRefPubMed Orjuela-Sanchez P, da Silva NS, da Silva-Nunes M, Ferreira MU: Recurrent parasitemias and population dynamics of Plasmodium vivax polymorphisms in rural Amazonia. Am J Trop Med Hyg. 2009, 81: 961-968.CrossRefPubMed
33.
go back to reference Bruce MC, Galinski MR, Barnwell JW, Donnelly CA, Walmsley M, Alpers MP, Walliker D, Day KP: Genetic diversity and dynamics of Plasmodium falciparum and P. vivax populations in multiply infected children with asymptomatic malaria infections in Papua New Guinea. Parasitology. 2000, 121 (Pt 3): 257-272.CrossRefPubMed Bruce MC, Galinski MR, Barnwell JW, Donnelly CA, Walmsley M, Alpers MP, Walliker D, Day KP: Genetic diversity and dynamics of Plasmodium falciparum and P. vivax populations in multiply infected children with asymptomatic malaria infections in Papua New Guinea. Parasitology. 2000, 121 (Pt 3): 257-272.CrossRefPubMed
34.
go back to reference Kolakovich KA, Ssengoba A, Wojcik K, Tsuboi T, Al-Yaman F, Alpers M, Adams JH: Plasmodium vivax: favored gene frequencies of the merozoite surface protein-1 and the multiplicity of infection in a malaria endemic region. Exp Parasitol. 1996, 83: 11-19.CrossRefPubMed Kolakovich KA, Ssengoba A, Wojcik K, Tsuboi T, Al-Yaman F, Alpers M, Adams JH: Plasmodium vivax: favored gene frequencies of the merozoite surface protein-1 and the multiplicity of infection in a malaria endemic region. Exp Parasitol. 1996, 83: 11-19.CrossRefPubMed
35.
go back to reference Ferreira MU, Karunaweera ND, da Silva-Nunes M, da Silva NS, Wirth DF, Hartl DL: Population structure and transmission dynamics of Plasmodium vivax in rural Amazonia. J Infect Dis. 2007, 195: 1218-1226.CrossRefPubMed Ferreira MU, Karunaweera ND, da Silva-Nunes M, da Silva NS, Wirth DF, Hartl DL: Population structure and transmission dynamics of Plasmodium vivax in rural Amazonia. J Infect Dis. 2007, 195: 1218-1226.CrossRefPubMed
36.
go back to reference Cui L, Escalante AA, Imwong M, Snounou G: The genetic diversity of Plasmodium vivax populations. Trends Parasitol. 2003, 19: 220-226.CrossRefPubMed Cui L, Escalante AA, Imwong M, Snounou G: The genetic diversity of Plasmodium vivax populations. Trends Parasitol. 2003, 19: 220-226.CrossRefPubMed
Metadata
Title
Global and local genetic diversity at two microsatellite loci in Plasmodium vivax parasites from Asia, Africa and South America
Authors
Mette L Schousboe
Samir Ranjitkar
Rupika S Rajakaruna
Priyanie H Amerasinghe
Flemming Konradsen
Francisco Morales
Rosalynn Ord
Richard Pearce
Toby Leslie
Mark Rowland
Nahla Gadalla
Ib C Bygbjerg
Michael Alifrangis
Cally Roper
Publication date
01-12-2014
Publisher
BioMed Central
Published in
Malaria Journal / Issue 1/2014
Electronic ISSN: 1475-2875
DOI
https://doi.org/10.1186/1475-2875-13-392

Other articles of this Issue 1/2014

Malaria Journal 1/2014 Go to the issue
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.