The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology

Fatal recurrence of fulminant giant cell myocarditis and recovery after initialisation of an alternative immunosuppressive regime

We report on a challenging case of a 34-year-old male patient with giant cell myocarditis (GCM) and fulminant relapse after discontinuing immunomodulatory therapy 2 years after the initial event. Specific combined immunosuppressive therapy with antithymocyte globulin (ATG), cyclosporine and high-dose glucocorticoids combined with guideline-based heart failure medication led to the recovery of GCM, improvement of systolic left ventricular function and clinical remission. This case report emphasises the importance of an immunosuppressive therapy for the prognosis and outcome and the risk of discontinuation. Most importantly, ATG seems to be one new possible potential treatment option for patients with acute GCM.

Electrogram guidance: a method to increase the precision and diagnostic yield of endomyocardial biopsy for suspected cardiac sarcoidosis and myocarditis

OBJECTIVES

The aim of this study was to describe the method used to perform electrogram-guided EMB and correlate electrogram characteristics with pathological and clinical outcomes.

BACKGROUND

Endomyocardial biopsy (EMB) is valuable in determining the underlying etiology of a cardiomyopathy. The sensitivity, however, for focal disorders, such as lymphocytic myocarditis and cardiac sarcoidosis (CS), is low. The sensitivity of routine fluoroscopically guided EMB is low. Abnormal intracardiac electrograms are seen at sites of myocardial disease. However, the exact value of electrogram-guided EMB is unknown.

METHODS

We report 11 patients who underwent electrogram-guided EMB for evaluation of myocarditis and CS.

RESULTS

Of 40 total biopsy specimens taken from 11 patients, 19 had electrogram voltage <5 mV, all of which resulted in histopathologic abnormality (100% specificity and positive predictive value). A voltage amplitude cutoff value of 5 mV had substantially higher sensitivity (70% vs. 26%) and negative predictive value (62%) than 1.5 mV. Abnormal electrogram appearance at biopsy site had good sensitivity (67%) and specificity (92%) in predicting abnormal myocardium. Normal signals with voltage >5 mV signified normal myocardium with no significant diagnostic yield. Biopsy results guided therapy in all patients, including 5 with active myocarditis or CS, all of whom subsequently received immunosuppressive therapy. There were no procedural complications.

CONCLUSIONS

In patients with suspected myocarditis or CS, electrogram-guided EMB targeting sites with abnormal or low-amplitude electrograms may increase the diagnostic yield for detecting abnormal pathological findings.

Machines versus medication for biventricular heart failure: focus on the total artificial heart

ABSTRACT 

The medical/surgical management of advanced heart failure has evolved rapidly over the last few decades. With better understanding of heart failure pathophysiology, new pharmacological agents have been introduced that have resulted in improvements in survival. For those patients that fail to improve, mechanical circulatory support with left ventricular assist devices and total artificial hearts (TAHs) have served as a beneficial bridge to transplantation. The TAH has continued to play a significant role as a bridge to transplantation in patients with biventricular failure and more selected indications that could not be completely helped with left ventricular assist devices. Improved survival with the TAH has resulted in more patients benefiting from this technology. Improvements will eventually lead to a totally implantable device that will permanently replace the failing human heart.

Neopterin and beta-2 microglobulin relations to immunity and inflammatory status in nonischemic dilated cardiomyopathy patients

BACKGROUND

The aim of the study was to assess the relationships among serum neopterin (NPT), β2-microglobulin (β2-M) levels, clinical status, and endomyocardial biopsy results of dilated cardiomyopathy patients (DCM).

METHODS

Serum NPT and β-2 M were determined in 172 nonischaemic DCM patients who underwent right ventricular endomyocardial biopsy and 30 healthy subjects (ELISA test). The cryostat biopsy specimens were assessed using histology, immunohistology, and immunochemistry methods (HLA ABC, HLA DR expression, CD3 + lymphocytes, and macrophages counts).

RESULTS

The strong increase of HLA ABC or HLA DR expression was detected in 27.2% patients-group A-being low in 72.8% patients-group B. Neopterin level was increased in patients in group A compared to healthy controls 8.11 (4.50-12.57) versus 4.99 (2.66-8.28) nmol/L (P < 0.05). β-2 microglobulin level was higher in DCM groups A (2.60 (1.71-3.58)) and B (2.52 (1.51-3.72)) than in the control group 1.75 (1.28-1.96) mg/L, P < 0.001. Neopterin correlated positively with the number of macrophages in biopsy specimens (P < 0.05) acute phase proteins: C-reactive proteins (P < 0.05); fibrinogen (P < 0.01); and NYHA functional class (P < 0.05) and negatively with left ventricular ejection fraction (P < 0.05).

CONCLUSIONS

Neopterin but not β-2 microglobulin concentration reflected immune response in biopsy specimens. Neopterin correlated with acute phase proteins and stage of heart failure and may indicate a general immune and inflammatory activation in heart failure.

Brief report: antisynthetase syndrome-associated myocarditis

BACKGROUND

The antisynthetase (AS) syndrome is characterized by autoimmune myopathy, interstitial lung disease, cutaneous involvement, arthritis, fever, and antibody specificity. We describe 2 patients with AS syndrome who also developed myocarditis, depressed biventricular function, and congestive heart failure.

METHODS AND RESULTS

Both patients were diagnosed with AS syndrome based on clinical manifestations, detection of serum AS antibodies, and myositis confirmation with the use of skeletal muscle magnetic resonance imaging and skeletal muscle biopsy. In addition, myocarditis resulting in heart failure was confirmed with the use of cardiac magnetic resonance imaging and from endomyocardial biopsy findings. After treatment for presumed AS syndrome-associated myocarditis, one patient recovered and the other patient died.

CONCLUSIONS

AS syndrome is a rare entity with morbidity and mortality typically attributed to myositis and lung involvement. This is the first report of AS syndrome-associated myocarditis leading to congestive heart failure in 2 patients. Given the potentially fatal consequences, myocarditis should be considered in patients with AS syndrome presenting with heart failure.

Quantification of myocardial fibrosis by digital image analysis and interactive stereology

BACKGROUND

Cardiac fibrosis disrupts the normal myocardial structure and has a direct impact on heart function and survival. Despite already available digital methods, the pathologist's visual score is still widely considered as ground truth and used as a primary method in histomorphometric evaluations. The aim of this study was to compare the accuracy of digital image analysis tools and the pathologist's visual scoring for evaluating fibrosis in human myocardial biopsies, based on reference data obtained by point counting performed on the same images.

METHODS

Endomyocardial biopsy material from 38 patients diagnosed with inflammatory dilated cardiomyopathy was used. The extent of total cardiac fibrosis was assessed by image analysis on Masson's trichrome-stained tissue specimens using automated Colocalization and Genie software, by Stereology grid count and manually by Pathologist's visual score.

RESULTS

A total of 116 slides were analyzed. The mean results obtained by the Colocalization software (13.72 ± 12.24%) were closest to the reference value of stereology (RVS), while the Genie software and Pathologist score gave a slight underestimation. RVS values correlated strongly with values obtained using the Colocalization and Genie (r>0.9, p<0.001) software as well as the pathologist visual score. Differences in fibrosis quantification by Colocalization and RVS were statistically insignificant. However, significant bias was found in the results obtained by using Genie versus RVS and pathologist score versus RVS with mean difference values of: -1.61% and 2.24%. Bland-Altman plots showed a bidirectional bias dependent on the magnitude of the measurement: Colocalization software overestimated the area fraction of fibrosis in the lower end, and underestimated in the higher end of the RVS values. Meanwhile, Genie software as well as the pathologist score showed more uniform results throughout the values, with a slight underestimation in the mid-range for both.

CONCLUSION

Both applied digital image analysis methods revealed almost perfect correlation with the criterion standard obtained by stereology grid count and, in terms of accuracy, outperformed the pathologist's visual score. Genie algorithm proved to be the method of choice with the only drawback of a slight underestimation bias, which is considered acceptable for both clinical and research evaluations.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/9857909611227193.

Management of fulminant myocarditis: a diagnosis in search of its etiology but with therapeutic options

Fulminant myocarditis is a clinical syndrome with signs of acute heart failure, cardiogenic shock, or life-threating rhythm disturbances in the context of suspected myocarditis. It is not an etiological diagnosis, but may have different underlying causes and pathogenetic processes - viral, bacterial, toxic, and autoreactive. Clinical management of the disease entity at the acute stage involves hemodynamic monitoring in an intensive care unit or similar setting. Rapid routine work-up is mandatory with serial EKGs, echocardiography, cardiac MRI, heart catheterization with endomyocardial biopsy for histology, immunohistology, and molecular analysis for the underlying infection and pathogenesis. Heart failure therapy is warranted in all cases according to current guidelines. For fulminant autoreactive myocarditis, immunosuppressive treatment is beneficial; for viral myocarditis, IVIg can resolve the inflammation, reduce the viral load, and even eradicate the microbial agent. ECMO, IABP, ventricular assist devices, LifeVest, or ICD implantation can bridge to recovery or to heart transplantation.

Gremlin-1 identifies fibrosis and predicts adverse outcome in patients with heart failure undergoing endomyocardial biopsy

BACKGROUND

Gremlin-1 (Grem1), an antagonist of bone morphogenetic proteins, is involved in fibrotic tissue formation in kidney and lung. The impact of myocardial Grem1 expression is unknown. We investigated the prognostic value of Grem1 expression in 214 consecutive patients with nonischemic heart failure (HF) undergoing endomyocardial biopsy.

METHODS

In all patients, the following risk factors were assessed: Grem1 expression (semiquantitative score scheme ranging from 1 to 4), presence of inflammatory markers, detection of viral genome, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), New York Heart Association functional class (NYHA), troponin I, and B-type natriuretic peptide. Degree of myocardial fibrosis was defined as an index. Study end point was a combination of all-cause death and HF-related rehospitalization within 3 years of follow-up.

RESULTS

Grem1 expression significantly correlated with the degree of myocardial fibrosis (correlation coefficient r = 0.619; P < .0001). Patients with the highest Grem1 expression (score 4) showed the most severely impaired LVEF and highest LVEDD (P < .0001 and P = .030, respectively, for comparison of semiquantitative scores). During follow-up, 33 patients (15.4%) reached the study end point. Grem1 expression and NYHA ≥II were independent predictors of the end point (Grem1: hazard ratio [HR] 7.5, 95% confidence interval [CI] 1.8-32.2; P = .006; NYHA ≥II: HR 2.0, 95% CI 1.0-4.1; P = .048).

CONCLUSIONS

Grem1 correlates with the degree of myocardial fibrosis and left ventricular dysfunction and is an independent predictor of adverse outcome in patients with nonischemic HF.

Native T1-mapping detects the location, extent and patterns of acute myocarditis without the need for gadolinium contrast agents

BACKGROUND

Acute myocarditis can be diagnosed on cardiovascular magnetic resonance (CMR) using multiple techniques, including late gadolinium enhancement (LGE) imaging, which requires contrast administration. Native T1-mapping is significantly more sensitive than LGE and conventional T2-weighted (T2W) imaging in detecting myocarditis. The aims of this study were to demonstrate how to display the non-ischemic patterns of injury and to quantify myocardial involvement in acute myocarditis without the need for contrast agents, using topographic T1-maps and incremental T1 thresholds.

METHODS

We studied 60 patients with suspected acute myocarditis (median 3 days from presentation) and 50 controls using CMR (1.5 T), including: (1) dark-blood T2W imaging; >(2) native T1-mapping (ShMOLLI); (3) LGE. Analysis included: (1) global myocardial T2 signal intensity (SI) ratio compared to skeletal muscle; (2) myocardial T1 times; (3) areas of injury by T2W, T1-mapping and LGE.

RESULTS

Compared to controls, patients had more edema (global myocardial T2 SI ratio 1.71 ± 0.27 vs.1.56 ± 0.15), higher mean myocardial T1 (1011 ± 64 ms vs. 946 ± 23 ms) and more areas of injury as detected by T2W (median 5% vs. 0%), T1 (median 32% vs. 0.7%) and LGE (median 11% vs. 0%); all p < 0.001. A threshold of T1 > 990 ms (sensitivity 90%, specificity 88%) detected significantly larger areas of involvement than T2W and LGE imaging in patients, and additional areas of injury when T2W and LGE were negative. T1-mapping significantly improved the diagnostic confidence in an additional 30% of cases when at least one of the conventional methods (T2W, LGE) failed to identify any areas of abnormality. Using incremental thresholds, T1-mapping can display the non-ischemic patterns of injury typical of myocarditis.

CONCLUSION

Native T1-mapping can display the typical non-ischemic patterns in acute myocarditis, similar to LGE imaging but without the need for contrast agents. In addition, T1-mapping offers significant incremental diagnostic value, detecting additional areas of myocardial involvement beyond T2W and LGE imaging and identified extra cases when these conventional methods failed to identify abnormalities. In the future, it may be possible to perform gadolinium-free CMR using cine and T1-mapping for tissue characterization and may be particularly useful for patients in whom gadolinium contrast is contraindicated.

The Changing Role for Endomyocardial Biopsy in the Diagnosis of Giant-Cell Myocarditis

Endomyocardial biopsy (EMB) is central to the diagnosis of giant-cell myocarditis (GCM) and planning further management. There is, however, no guideline-directed recommendation on re-biopsy or left ventricular EMB in a suspected case of acute, fulminant myocarditis following an indeterminate first biopsy. This manuscript illustrates, with a case, the changing role for EMB in the current era in the diagnosis of GCM.

ST elevation without myocardial infarction

Acute myocarditis may mimic myocardial infarction because the affected patients report 'classical' chest pain; the ECG changes and echocardiography are identical to those observed in acute coronary syndromes, and serum markers are increased. We describe a case with ST segment elevation on admission ECG, and coronary angiography was normal. Cardiac magnetic resonance with myocardial delayed enhancement sequences is a non-invasive alternative for diagnosing myocarditis.

Role of imaging in the diagnosis and management of patients with cardiac amyloidosis: state of the art review and focus on emerging nuclear techniques

Amyloidosis is an infiltrative disease characterized by deposition of amyloid fibrils within the extracellular tissue of one or multiple organs. Involvement of the heart, cardiac amyloidosis, is recognized as a common cause of restrictive cardiomyopathy and heart failure. The two major types of cardiac amyloidosis are cardiac amyloid light-chain (AL) and transthyretin-related cardiac amyloidosis (ATTR, mutant and wild types) (Nat Rev Cardiol 2010;7:398-408). While early recognition of cardiac amyloidosis is of major clinical importance, so is the ability to differentiate between subtypes. Indeed, both prognosis and therapeutic options vary drastically depending on the subtype. While endomyocardial biopsy with immunostaining is considered the gold standard, advances in imaging provide an attractive non-invasive alternative. Currently, electrocardiography, echocardiography, and cardiac magnetic resonance imaging are all used in the evaluation of cardiac amyloidosis with varying diagnostic and prognostic accuracy. Yet, none of these modalities can effectively differentiate the cardiac amyloid subtypes. Recent data with (99m)Tc-phosphate derivatives, previously used as bone seeking radioactive tracers, have shown promising results; these radiotracers selectively bind ATTR, but not AL subtype, and can differentiate subtypes with high diagnostic accuracy. This review will initially present the non-radionuclide imaging techniques and then focus on the radionuclide imaging techniques, particularly (99m)Tc-DPD and (99m)Tc-PYP, mechanism of action, performance and interpretation of the study, diagnostic accuracy, prognostic value, future clinical perspective, and outlook.

When should we consider the diagnosis of giant cell myocarditis? Revisiting "classic" echocardiographic and clinical features of this rare pathology

OBJECTIVES

Giant cell myocarditis is a rare and often fatal disorder. According to the American Heart Association, the American College of Cardiology Foundation, and the European Society of Cardiology scientific statements, an endomyocardial biopsy should be done to exclude giant cell myocarditis in unexplained new-onset heart failure of 2 weeks to 3 months duration associated with dilated left ventricle and new ventricular arrhythmias, or Mobitz type II second-degree, or third-degree atrioventricular heart block.

CASE PRESENTATIONS

Two hundred thirty-five heart transplants were performed since May 1993 at the Institut universitaire de cardiologie et de pneumologie de Quebec, Canada. Giant cell myocarditis was found in the explanted hearts of 5 patients. The preoperative diagnosis of giant cell myocarditis was done by endomyocardial biopsy or at the installation of a left ventricular-assisted device. Patients had symptoms of progressive heart failure of subacute onset. Patients consulted at a mean 32 days after the onset of symptoms. Two patients neither had ventricular arrhythmia nor heart block. Two patients had ventricular arrhythmias and heart block; the other patient had symptomatic heart block. All patients had at least 2 echocardiographies. Two patients had an increase in left ventricular size, enough to reach the criteria of left ventricular dilatation according to the American Society of Echocardiography. During this time, left ventricular ejection fraction showed a rapid decline (mean 37% to 16%).

CONCLUSIONS

Ventricular arrhythmia, heart block, and left ventricular dilatation initially can be absent in many patients having giant cell myocarditis with symptoms of progressive heart failure. Endo-myocardial biopsy should be quickly considered in patients with a rapid and dramatic decline of left ventricular ejection fraction, even in the absence of classic clinical and echocardiographic features of giant cell myocarditis to rapidly obtain the diagnosis of this rare but lethal disease.

Nuclear imaging modalities for cardiac amyloidosis

Amyloidosis is a heterogeneous group of diseases characterized by localized or systemic deposition of insoluble extracellular fibrillary proteins in organs and tissues. Several types of amyloid can infiltrate the heart resulting in a restrictive cardiomyopathy, heart failure, and atrial and ventricular arrhythmias. Scintigraphy is a noninvasive method that may facilitate early diagnosis, distinguish various forms of cardiac amyloid, and may be useful in following disease burden. The amyloid-specific tracers presented in this article have been used with planar imaging and/or single-photon emission computed tomography. To date, there are no approved cardiac amyloid tracers although investigational tracers are currently under examination. This article serves to review the current nuclear imaging modalities available in the detection of cardiac amyloid.

Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis

BACKGROUND

The diagnosis of myocarditis is challenging due to its varying clinical presentation. Since myocarditis can be associated with significant 5-year mortality, and postmortem data show myocarditis in almost 10% of all adults suffering sudden cardiac death, individual risk stratification for patients with suspected myocarditis is of great clinical interest. We sought to demonstrate that patients with clinically suspected myocarditis and a normal cardiovascular magnetic resonance (CMR) according to our definition have a good prognosis, independent of their clinical symptoms and other findings.

METHODS

Prospective clinical long-term follow-up of consecutive patients undergoing CMR for work-up of clinically suspected myocarditis at our institution in 2007-2008.

RESULTS

Follow-up was available for n=405 patients (all-comers, 54.8% inpatients, 38% outpatient referrals from cardiologists). Median follow-up time was 1591 days. CMR diagnosis was "myocarditis" in 28.8%, "normal" in 55.6% and "other pathology" in 15.6%. Normal CMR was defined as normal left ventricular (LV) volumes and normal left ventricular ejection fraction (LV-EF) in the absence of late Gadolinium Enhancement (LGE). The overall mortality was 3.2%. There were seven cardiac deaths during follow-up, in addition one aborted SCD and two patients had appropriate internal cardioverter defibrillator (ICD) shocks - all of these occurred in patients with abnormal CMR. Kaplan-Meier analysis with log-rank test showed significant difference for major adverse cardiac events (cardiac death, sudden cardiac death (SCD), ICD discharge, aborted SCD) between patients with normal and abnormal CMR (p=0.0003).

CONCLUSION

In our unselected population of consecutive patients referred for CMR work-up of clinically suspected myocarditis, patients with normal CMR have a good prognosis independent of their clinical symptoms and other findings.

Detailed pathologic evaluation on endomyocardial biopsy provides long-term prognostic information in patients with acute myocarditis

BACKGROUND

The long-term prognosis of biopsy-proven myocarditis is not well known. We hypothesized that a detailed pathological examination of an endomyocardial biopsy (EMB) would reveal prognostic information in patients with acute myocarditis.

METHODS

Fifty-four patients were diagnosed with acute myocarditis based on an EMB. Pathological diagnosis was categorized into lymphocytic dominant (29.6%), eosinophilic dominant (22.2%), and borderline myocarditis (48.1%). Masson's trichrome staining and further immunohistochemical staining for CD3, CD20, CD68, HLA-DR, TLR4, TLR8, enteroviral VP1, and caspase-3 expression were performed. The clinical outcomes were defined as all-cause and cardiovascular (CV) death.

RESULTS

During the median 10.4 years of follow up (9.7±5.7 years), the overall all-cause mortality was 20.4% and the CV mortality was 14.8% in patients with acute myocarditis. Lymphocytic dominant myocarditis patients showed a poor clinical outcome when compared with eosinophilic dominant myocarditis patients for both all-cause (37.5% vs. 0%, p=0.015) and CV (31.2% vs. 0%, p=0.029) mortality. Among borderline myocarditis patients, the presence of fibrosis was linked with poor clinical outcomes in both all-cause (75.0% vs. 21.4%, p=0.045) and CV (100.0% vs. 25.0%, p=0.034) mortality. No significant associations between clinical outcome and all other immunohistochemical staining targets were observed.

CONCLUSIONS

Detailed pathological evaluation on an EMB provides prognostic information in patients with acute myocarditis. EMB evaluation should be considered in patients with suspected myocarditis.

Myocardial expression level of neural cell adhesion molecule correlates with reduced left ventricular function in human cardiomyopathy

BACKGROUND

Recently, we screened for cardiac genes induced by metabolic stress and identified neural cell adhesion molecule (NCAM) as a candidate. This study aimed to clarify the expression pattern of NCAM in human cardiomyopathy.

METHODS AND RESULTS

A total of 64 cardiac tissue samples of patients with dilated cardiomyopathy were dichotomized according to the immunohistochemically determined signal intensity of NCAM staining (NCAM-high and NCAM-low groups). Clinical and hemodynamic data of the patients were compared between the 2 groups. Fibrosis area, left ventricular end-diastolic volume index, and left ventricular diastolic pressure were greater in the NCAM-high group (22.8% versus 11.6%, P<0.05; 130.3±57.6 versus 104.8±31.7 mL/m(2), P<0.05; 14.3±8.0 versus 8.8±4.7 mm Hg, P<0.005; respectively). Incidence of cardiac death and admission for worsening heart failure was higher in the NCAM-high group during a follow-up of 6.3 years (log-rank P<0.05). Another 18 tissue samples were analyzed to determine the relationships between expression level of NCAM and major metabolic genes as well as hemodynamic parameters. The mRNA level of NCAM correlated with the serum (r=0.58; P=0.01) and mRNA levels (r=0.61; P=0.008) of brain-derived natriuretic peptides. It was also correlated with the mRNA levels of proliferator-activated receptor-γ coactivator-1 α (r=0.69; P=0.002) and the nuclear respiratory factor 1 (r=0.74; P<0.001).

CONCLUSIONS

Expression of NCAM was associated with worsening hemodynamic parameters and major metabolic genes. Together with our previous findings, these data support the involvement of NCAM in left ventricular remodeling, revealing new insights into the pathophysiology of heart failure.

Potentially simple score of late gadolinium enhancement cardiac MR in acute myocarditis outcome

PURPOSE

To determine the value of cardiac MRI for the monitoring and the prognosis of patients with acute myocarditis. Cardiac MRI plays an increasingly important role in the diagnosis of acute myocarditis. However, it is less established as a prognostic tool, which requires specific postprocessing of images.

MATERIALS AND METHODS

In a prospective pilot study, we assessed the prognostic value of the evolution in a simplified visual quantitative score (SQS) of late gadolinium enhancement (LGE) between initial hospitalization and 3 months later. The prognostic value was assessed at 1 year using a combination of death, heart transplant, and confirmed recurrence as main outcome.

RESULTS

Twenty-eight patients were included in this study. A significant correlation was found between LGE measured by SQS and planimetry (r = 0.95, P < 0.001). Intraobserver and interobserver reproducibilities were good for SQS (ICC = 0.95 [95% CI: 0.86 to 0.98], and 0.94 [95% CI: 0.84 to 0.98], respectively). At initial hospitalization, patient characteristics between the two groups were similar. Patients with stable or increased SQS suffered more frequently from clinical outcome events than patients with a decrease in SQS (P = 0.02).

CONCLUSION

Monitoring of the evolution of LGE using a simple visual score is of interest to identify patients at risk of pejorative prognosis after acute myocarditis.

Evaluation of patients with heart failure

Heart failure is one of the most prevalent cardiovascular diseases in the United States, and is associated with significant morbidity, mortality, and costs. Prompt diagnosis may help decrease mortality, hospital stay, and costs related to treatment. A complete heart failure evaluation comprises a comprehensive history and physical examination, echocardiogram, and diagnostic tools that provide information regarding the etiology of heart failure, related complications, and prognosis in order to prescribe appropriate therapy, monitor response to therapy, and transition expeditiously to advanced therapies when needed. Emerging technologies and biomarkers may provide better risk stratification and more accurate determination of cause and progression.

Advanced imaging of cardiac sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Cardiac involvement may occur, leading to an adverse outcome. Although early treatment to improve morbidity and mortality is desirable, sensitive and accurate detection of cardiac sarcoidosis remains a challenge. Accordingly, interest in the use of advanced imaging such as cardiac MR and PET with (18)F-FDG is increasing in order to refine the clinical workup. Although the field is still facing challenges and uncertainties, this article presents a summary of clinical background and the current state of diagnostic modalities and treatment of cardiac sarcoidosis.

Pericardioscopy and epi- and pericardial biopsy - a new window to the heart improving etiological diagnoses and permitting targeted intrapericardial therapy

The etiology of pericardial effusions remains unresolved in many cases because not the full spectrum of diagnostic methods including cytology, histology, immunohistology and PCR on cardiotropic agents, which are currently available, used in many institutions. After comprehensive clinical workup and use of imaging methods, such as echocardiography and cardiac MRI, pericardiocentesis and epicardial and pericardial biopsy were carried out under pericardioscopical control of the biopsy site. Biopsies and fluid were evaluated by cytological, histological, immunological and molecular (PCR) methods in 259 patients of our tertiary referral center following an identical clinical pathway, diagnostic and therapeutic algorithm in all cases. A standard clinical pathway and the same diagnostic and therapeutic algorithms were used in all cases. When all methods are applied to patients with pericardial effusions, "idiopathic" pericardial effusion is no longer a relevant diagnosis. Autoreactive and lymphocytic pericardial effusions are the leading diagnosis in 35 % of patients in the prospective Marburg registry, followed by malignant effusions in 28 % of cases. Viral genome was assessed in fluid and epi- as well as pericardial biopsies in 12 %, followed by post-traumatic/iatrogenic effusions in 15 % and purulent/bacterial effusions in only 2 %. Pericardioscopy permits the macroscopic inspection of the pulsating heart and its disease-associated macroscopic alterations. It also permits safe and targeted biopsy for further investigations of the tissue. Therapy, tailored to the individual etiology, can be selected such as intrapericardial instillation in autoreactive effusions with triamcinolone and with cisplatin or thiotepa in neoplastic effusions. With this approach the recurrence of pericardial effusion can be avoided effectively. A comprehensive approach to the diagnosis of pericardial effusions in conjunction with pericardioscopy for targeted tissue sampling is the prerequisite for an etiologically based intrapericardial and systemic treatment, which improves outcome and prognosis.

Fulminant myocarditis

Myocarditis is most often caused by a viral infection. Less common causes include other infectious agents and autoimmune diseases. Fulminant myocarditis is an unusual complication with a rapidly progressive course resulting in severe heart failure and cardiogenic shock. Fulminant myocarditis should be treated with full supportive care, using aggressive pharmacologic therapy and mechanical circulatory support, because significant improvement in left ventricular function will often occur. Cardiac transplantation is required in a small minority of patients. Cardiac magnetic resonance imaging is becoming a frequently used modality to aid in the diagnosis of myocarditis.