Endomyocardial fibrosis: report of eight cases

Endomyocardial fibrosis related sudden cardiac death; two autopsied case-reports from Egypt

Endomyocardial fibrosis (EMF) is an idiopathic tropical disorder that is characterized by the development of restrictive cardiomyopathy. Neglected EMF can cause sudden cardiac death (SCD) in adults. Conclusive diagnosis of EMF depends on autopsy after death. In an effort to attract the interest of the community for this rare disease, we report two cases of SCD that were diagnosed as EMF during autopsy in Egypt. Both cases were thoroughly investigated with emphasis on death circumstances and post-mortem anatomical and histopathological findings. The two cases were for adult males presented with SCD following a quarrel with a negative medical history and family history regarding cardiac diseases. No trauma or drug abuse. The autopsy revealed hypertrophied hearts, thick fibrosed endocardium, patchy myocardial fibrosis, and filling of the apex by fibrosis and calcifications. In one of them, there was a huge mural thrombus reaching the level of the mitral valve that totally occluded the cavity of the left ventricle. Histopathologically, fibrosis was confirmed, and no eosinophils were detected. In contrast to previously reported cases in Egypt, the left ventricle was solely affected. Despite the rarity of the disease outside the tropics, the frequency of EMF cases is more likely to be more than the number of reported cases. EMF should be considered as possible cause of SCD during autopsy. Further studies are needed to clarify the etiology and epidemiology of EMF.

Endomyocardial fibrosis in Sudan: clinical and echocardiographic features

Objective:

Endomyocardial fibrosis (EMF) is a rare disease and is often an underdiagnosed and forgotten cardiomyopathy. The objective of this study was to document the current frequency of EMF in Sudan by defining and selecting cases from patients attending the echocardiography laboratory. Additionally we aimed to create an EMF registry for Sudan.

Methods:

The study started in January 2007 and is on-going. All the patients attending our echocardiography clinics in four different hospitals in Khartoum, Sudan, were included. Transthoracic echocardiography was used as the main diagnostic and selection tool. The diagnosis of EMF was based on predefined criteria and definitions, and was further supported by additional clinical, ECG, laboratory and chest X-ray findings.

Results:

Out of 4 332 cases studied, 23 (0.5%) were found to have features of EMF. Females constituted 52% and the age range was 24 to 67 years. All patients presented with dyspnoea grades III–IV. Advanced heart failure with gross fluid overload was seen in 54% of cases and ascites was seen in 30%. EMF was biventricular in 53%, left ventricular in 29% and right ventricular in 18% of cases. Apical and ventricular wall fibrosis was found in all cases, followed by atrial enlargement, atrioventricular valve incompetence, ventricular cavity obliteration, restrictive flow pattern and pericardial effusion. Additional echocardiographic features are defined and discussed.

Conclusion:

Although a rare disease, cases of EMF can be identified in Sudan if a high index of suspicion is observed. New echocardiographic features of ventricular wall layering, endocardial fibrous shelf and endomyocardiopericarial fibrosis were identified and are discussed.

The changing pattern of endomyocardial fibrosis in South-west Nigeria

Background:

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy, the prevalence of which is declining globally. This study was carried out to determine if there were changing patterns in its local prevalence in South-West Nigeria.

Methods:

We reviewed the medical records of all patients admitted to or attending the cardiology clinic or medical outpatient/specialty clinics in the Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, South-West Nigeria. Medical data for those with EMF from January 2003 to December 2009 were retrieved and analyzed.

Results:

Only three cases of EMF were identified from a total of 12,794 medical patients containing a subset of 7956 cardiac patients. The prevalence of EMF was 0.02% and 0.04% for medical and cardiac patients, respectively. All the patients with EMF were in the second or third decades of life, and had right ventricular EMF and atrial fibrillation, but no eosinophilia.

Conclusion:

This study shows that the prevalence of EMF has declined in the study area from 10% in the 1960s and 1970s to 0.02% for medical cases and 0.04% for cardiac cases in the first decade of the 21st century. Right ventricular EMF still predominates, but without eosinophilia. Improved health care delivery’s positive impact on the control of communicable diseases might be responsible for these observed changes. More work needs to be done both within and outside Nigeria to follow this trend and unravel the mystery surrounding this poorly understood cardiac disease.

Current status of endomyocardial biopsy

Endomyocardial biopsy (EMB) is widely used for surveillance of cardiac allograft rejection and for the diagnosis of unexplained ventricular dysfunction. Typically, EMB is performed through the jugular or femoral veins and is associated with a serious acute complication rate of less than 1% using current flexible bioptomes. Although it is accepted that EMB should be used to monitor for rejection after transplant, use of EMB for the diagnosis of various myocardial diseases is controversial. Diagnosis of myocardial disease in the nontransplant recipient is often successful via noninvasive investigations including laboratory evaluation; echocardiography, nuclear studies, and magnetic resonance imaging can yield specific diagnoses in the absence of invasive EMB. Therefore, use of the technique is patient specific and depends on the potential prognostic and treatment information gained by establishing a pathologic diagnosis beyond noninvasive testing.

Coronary blood flow by transthoracic echocardiography in children with endomyocardial fibrosis

We report herein the coronary flow (CF) pattern determined by transthoracic Doppler echocardiography (TTDE) in two children with biventricular endomyocardial fibrosis (EMF). Endomyocardial biopsy showed various degrees of cardiac fibrosis in both patients as well as signs of chronic inflammation in one of the patients. TTDE showed a significant increase in CF in both the left anterior descending coronary artery and the posterior descending coronary artery compared with age-matched healthy controls. The diastolic flow in patients with EMF appeared to terminate earlier than in controls. The mechanisms and the potential significance of these novel findings are discussed.

Endomyocardial fibrosis: an enigmatic cause for a giant left atrium

Endomyocardial fibrosis (EMF) was first described in 1948. It is an idiopathic disorder, characterized by the formation of fibrous tissue on the endocardial aspect of one or both ventricles, resulting in a restrictive cardiomyopathy with atrial enlargement. Originally described in Uganda, numerous cases have also been described in the Middle East.

Pitfalls in diagnosis and clinical, echocardiographic, and hemodynamic findings in endomyocardial fibrosis: a 25-year experience

Endomyocardial fibrosis (EMF) is a fascinating disease entity of unknown etiology. It is prevalent in the tropical zone. Its essential features are the formation of fibrous tissue on the endocardium and to a lesser extent in the myocardium of the inflow tract and apex of one or both ventricles. It results in endocardial rigidity, atrioventricular valve incompetence secondary to papillary muscle involvement, and progressive reduction of the cavity of the involved ventricle leading to restriction in filling and atrial enlargement. This article will present 21 patients with EMF who were initially referred to our hospital from 1979 to 2004 with different diagnoses: rheumatic heart disease with mitral and or tricuspid regurgitation (n = 9), constrictive pericarditis (n = 6), restrictive cardiomyopathy (n = 1), hypertrophic cardiomyopathy apical type (n = 2), dilated cardiomyopathy (n = 2), and Ebstein malfunction of the tricuspid valve (n = 1). The clinical, echocardiographic, hemodynamic, and angiographic findings in these 21 patients are presented; echocardiographic findings lead to the right diagnosis. The presence of a small ventricle with obliteration of the apex and large atrium shown on two-dimensional echocardiography is highly suggestive of EMF.

An adult case with an abnormal right ventricular structure causing intraventricular pressure gradient and a history of aphthous stomatitis and thrombophlebitis

We report a 50-year-old man with a right ventricular structure causing an intraventricular pressure gradient. He had been diagnosed as vasculo-Behçet with a history of aphthous stomatitis and thrombophlebitis. He had also been suffering from atrial flutter and mild right-side heart failure. Echocardiography showed that there was an abnormal structure attached to the right ventricular free wall and protruding into the cavity, and that it caused the pressure gradient estimated to be approximately 19 mmHg. Chest X-ray computed tomography demonstrated that the structure was partially calcified. Magnetic resonance imaging depicted the structure separating the right ventricle into two chambers. Angiographic study revealed a markedly enlarged right atrium and a filling defect at the mid-portion of the right ventricle, which divided the right ventricular cavity into two parts. Hemodynamic study showed a slightly elevated right atrial pressure (mean 7 mmHg) and a peak-to-peak intraventricular pressure difference of 18 mmHg in the right ventricle. The diastolic pressure tracing of the right ventricular low pressure chamber showed a 'dip and plateau' pattern. Although the pathological features of the abnormal right ventricular structure in this case were not fully clarified, abnormal muscle bundle and/or endocardial fibrosis, which were reported to be associated with Behçet's disease, may have contributed to its generation.

Endomyocardial fibrosis in Egypt: an illustrated review

The detailed features of right sided endomyocardial fibrosis are described in 15 out of 10,000 consecutive patients who all had infection with Schistosoma mansoni and came from rural Egypt. Laboratory investigations, 12 lead electrocardiography, chest radiography, and Doppler echocardiography were performed in all patients. Cardiac catheterisation and angiography were performed in eight. Endomyocardial biopsy specimens were obtained from the right ventricles of two patients and pericardial biopsy specimens from two. Pericardiocentesis was performed in all patients. All patients were infected with S mansoni and had schistosomal hepatic fibrosis and ascites. Eleven had splenomegaly. All patients had raised cervical venous pressure with prominent Y descent and atrial fibrillation. Eosinophilia was notably absent. Echocardiography showed apical fibrosis in the right ventricle, obliteration of the ventricle, and moderate to massive exudative pericardial effusion in all patients. Calcification and fibrosis extended into the right ventricular outflow tracts in two patients. Huge right atrial thrombi occurred in five patients. Tricuspid regurgitation (grades I-II) was detected in 11 patients by Doppler ultrasonography. Haemodynamic and angiographic data confirmed the pure right sided restrictive pathophysiology. Pericardial biopsy specimens showed perivascular inflammatory infiltrates in two patients and a schistosomal granuloma in one. Endocardial biopsy specimens showed dense fibrosis with many fibroblasts. Endomyocardial fibrosis in Egypt is unique in several aspects. It always affected only the right side of the heart. Calcification and fibrosis extended to the right ventricular outflow tract. Pericardial inflammatory reaction was present. The relation to schistosomiasis and the link to periportal hepatic fibrosis in these patients is intriguing.

Endomyocardial fibrosis: Clinical, echocardiographic and hemodynamic findings

Endomyocardial fibrosis (EMF) is a disease of unknown origin. It was first described by Davies in Uganda in 1948. The clinical enchocardiographic, and hemodynamic findings in 18 patients are presented. Six patients had right-sided involvement, four had left-sided involvement and eight had biventricular involvement. The presence of a small ventricle with obliteration of the apex and a large atrium, diagnosed by two-dimensional echocardiography, is highly suggestive of endomyocardial fibrosis. Ventricular angiography was diagnostic in 17 out of 18 cases. Endomyocardial biopsy yielded positive findings in three out of seven patients and is not essential for diagnosis. Two patients suffered a cerebral embolism. Six patients underwent surgery with good results in three patients.

Right-sided endomyocardial fibrosis with recurrent pulmonary emboli leading to irreversible pulmonary hypertension

A 26 year old Saudi man with features of both Loeffer's endocarditis and endomyocardial fibrosis presented with mild symptoms and pulmonary emboli. Echocardiographic examination showed obliteration of the right ventricular apex by an attached mass. The results of haemodynamic studies were somewhat abnormal and medical treatment was started. Despite anticoagulation with warfarin the patient's condition deteriorated rapidly over a four month period after a further episode of pulmonary embolism and the development of pulmonary hypertension. Two haemodynamic studies performed four months apart were typical of pulmonary hypertension and later right ventricular failure; they showed none of the characteristics of restriction. Pulmonary embolectomy was attempted but there was no cleavage plane between the organised thrombi and the endothelium of the pulmonary artery. The patient died of severe pulmonary hypertension and right ventricular failure several days after operation. Surgical intervention in the early stages of right-sided endomyocardial fibrosis might have prevented the development of pulmonary embolism and pulmonary hypertension.

Histomorphologic characteristics of endomyocardial fibrosis: an endomyocardial biopsy study

Endomyocardial biopsies from right, left, or both ventricles were performed in 13 angiographically documented cases of endomyocardial fibrosis. The endocardium was appreciably thickened due to acellular hyalinized collagen tissue in all cases. Variable amounts of elastic tissue intimately admixed with fibrous tissue were recognized. A "zonal layering" pattern of the endocardium was absent. Thrombus, inflammatory cells, and granulation tissue at the endomyocardial interphase, and eosinophils within the biopsy were not seen. In addition, lymphomononuclear interstitial inflammatory infiltrates were seen in five cases.

Endomyocardial fibrosis in a white girl with sero-positive juvenile rheumatoid arthritis

A white girl with sero-positive juvenile rheumatoid arthritis was subsequently found to have endomyocardial fibrosis. We believe that these two rare conditions were not causally related.