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

Contribution and Risks of Left Ventricular Endomyocardial Biopsy in Patients With Cardiomyopathies

Background—

Use of left ventricular (LV) endomyocardial biopsy (EMB) to investigate cardiomyopathies is currently discouraged because it is considered riskier than and as contributive as right ventricular (RV) biopsy. The aim of our study is to report our experience with this option and to discuss its advantages and disadvantages.

Methods and Results—

In our center from 1983 to 2010, 4221 patients underwent diagnostic EMB. In particular, 2396 (56.8%) underwent biventricular EMB, 1153 (27.3%) underwent selective LVEMB, and 672 (15.9%) underwent selective RVEMB. The rate of complications and histological findings were retrospectively analyzed. The periprocedural major complication rate (perforation with or without cardiac tamponade, embolization) was 0.33% for LVEMB and 0.45% for RVEMB, with a significant decrease in the rate of major complications with time (from 1.6% and 1.9% in 1983–1988 to 0% and 0.3% in 2007–2013, respectively; P <0.001 for both), denoting a steep learning curve. No patients died. When the structural and functional abnormalities affected exclusively the LV, the diagnostic yield of LVEMB was 97.8% compared with 53% for RVEMB. Conversely, when the echocardiographic presence of increased wall thickness, local or global ventricular dilation, or dysfunction also involved the RV, the diagnosis was reached in 98.1% of LVEMBs and 96.5% of RVEMBs. This discrepancy was particularly evident for myocarditis, whereas in infiltrative and storage diseases, the histological abnormalities were always detectable in both ventricles.

Conclusions—

LVEMB is a safe procedure with very low transient complications, comparable to RVEMB. It appears diagnostically more contributive than RVEMB in patients with cardiomyopathies and clinically preserved RV.

The effects of gender and age on occurrence of clinically suspected myocarditis in adulthood

OBJECTIVE

To study the effects of gender and age on occurrence of myocarditis.

DESIGN

Nationwide, multicentre registry study in Finland.

SETTING

All medical hospital admissions (n=1 698 397) of patients aged ≥ 16 years during 9.5 years in 29 hospitals.

PATIENTS

3198 myocarditis patients.

RESULTS

Myocarditis was more common in men (76.61%; 95% CI 75.11% to 78.05%) than in women (23.39%; 95% CI 21.95% to 24.89%, p<0.0001). Median age of patients was 33 years (IQR 23-50 years). Male patients were significantly younger than females (mean age 34.1 ± SD 15.1 vs 49.0 ± 18.7 years, p<0.0001). In men, occurrence was highest at 16-20 yrs of age, with a linear decline to elderliness (r=-0.95, p<0.0001). By contrast, myocarditis affected women more evenly at all ages with highest occurrence at the age of 56-60 years. Myocarditis caused 0.19% (95% CI 0.18% to 0.19%) of all medical admissions, and 0.48% (95% CI 0.46% to 0.49%) of admissions due to cardiovascular reasons with an inverse logarithmic association with age (r=-0.97, p<0.0001). Admissions were more commonly caused by myocarditis in men (risk ratio 3.11; 95% CI 2.87 to 3.38, p<0.0001).

CONCLUSIONS

Men are significantly more susceptible to myocarditis than women. Young men are especially at risk for acquiring myocarditis, while women are affected most commonly at the postmenopausal age. The proportion of hospital admissions caused by myocarditis has an inverse, logarithmic association with age.

Diastolic tissue Doppler indexes correlate with the degree of collagen expression and cross-linking in heart failure and normal ejection fraction

OBJECTIVES

We attempted to correlate echocardiographic analysis of diastolic function with changes of myocardial collagen in middle-aged patients with heart failure (HF) despite normal ejection fraction (EF).

BACKGROUND

Increased collagen deposition may contribute to the deterioration of the left ventricular compliance and diastolic dysfunction in HF.

METHODS

We investigated 41 patients (median age 50 years [interquartile range: 41 to 57 years]) with normal EF (median 62% [interquartile range: 56% to 70%]) whose endomyocardial biopsies were taken previously. Assessment of diastolic function was performed by mitral-flow and tissue Doppler measurements. Sirius red and immunohistologic staining was performed to determine collagen volume fraction (CVF) and cross-linking, collagen types I and III expression, and lysyl-oxidase (LOX) expression. Expression of collagen messenger ribonucleic acid was determined by real-time polymerase chain reaction.

RESULTS

Twenty-six patients with HFNEF with diastolic dysfunction showed a significant increase in total collagen and collagen I expression compared with that of 15 controls. This was accompanied with enhanced collagen cross-linking and LOX overexpression in HFNEF. Among all flow Doppler, only deceleration time of E was associated with CVF (R = 0.43), whereas tissue Doppler parameters correlated with CVF, collagen I at the protein and mRNA levels (E' [R = -0.58, -0.60, -0.45]; E'/A' [R = -0.32, -0.36, -0.31]), and left ventricular filling index (E/E' [R = 0.72, 0.68, 0.63]), respectively. No correlation with collagen III was found. The degree of collagen cross-linking and LOX expression was related to E' (R = -0.55 and -0.60) and E/E' (R = 0.72 and 0.71), respectively, but not to flow Doppler. Collagen overexpression correlated with reduced exercise capacity.

CONCLUSIONS

Patients with HFNEF showed increased content of myocardial collagen type I, enhanced collagen cross-linking, and LOX expression, which were associated with impaired diastolic tissue Doppler parameters.

Good prognosis for pericarditis with and without myocardial involvement: results from a multicenter, prospective cohort study

BACKGROUND

The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study.

METHODS AND RESULTS

A total of 486 patients (median age, 39 years; range, 18-83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P<0.001). Troponin elevation was not associated with an increase in complications.

CONCLUSIONS

The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.