Visualization of Endomyocardial Fibrosis by Delayed-Enhancement Magnetic Resonance Imaging

Cardiovascular Magnetic Resonance from Fetal to Adult Life-Indications and Challenges: A State-of-the-Art Review

Cardiovascular magnetic resonance (CMR) imaging offers a comprehensive, non-invasive, and radiation-free imaging modality, which provides a highly accurate and reproducible assessment of cardiac morphology and functions across a wide spectrum of cardiac conditions spanning from fetal to adult life. It minimises risks to the patient, particularly the risks associated with exposure to ionising radiation and the risk of complications from more invasive haemodynamic assessments. CMR utilises high spatial resolution and provides a detailed assessment of intracardiac and extracardiac anatomy, ventricular and valvular function, and flow haemodynamic and tissue characterisation, which aid in the diagnosis, and, hence, with the management of patients with cardiac disease. This article aims to discuss the role of CMR and the indications for its use throughout the different stages of life, from fetal to adult life.

Detection of a rare cause of pulmonary hypertension by multimodality imaging: Left ventricular endomyocardial fibrosis

Endomyocardial fibrosis (EMF), a restrictive cardiomyopathy characterized by subendocardial fibrosis, is commonly seen in tropical and subtropical regions. EMF involving the left ventricle presents with severe pulmonary hypertension (PH) and is a rare cause of PH in non-tropical areas. Multimodality imaging is important for accurate diagnosis, especially cardiac magnetic resonance imaging which is the cornerstone. Herein, we report the case of a patient who presented with heart failure symptoms and severe PH, and in whom EMF was diagnosed by multimodality imaging.

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.

Challenges in addressing the knowledge gap on endomyocardial fibrosis through community-based studies

Endomyocardial fibrosis (EMF) is a poverty-related disease of unknown origin that afflicts predominantly young people of certain rural areas in low-income countries and can be used to expose global disparities in cardiovascular research. Despite affecting predominantly young people and causing high morbidity and mortality, efforts to understand its mechanisms and natural history have been hampered by the incapacity to detect the early stages of the disease in endemic areas. Dietary, environmental and infectious factors seem to combine in susceptible individuals to give rise to an inflammatory process that leads to endomyocardial damage and scar formation. Lack of awareness by health professionals and low access to health care determine late diagnosis, when complications such as chronic heart failure, thromboembolism and arrhythmia are already present. Open-heart surgery to detach the endocardial fibrous tissue and repair the atrioventricular valve, remains the last resource to prolong patients' survival. Community-based research is therefore needed to understand the epidemiology of EMF, detect early disease, uncover its pathogenesis and explore new therapeutic targets. Our research has shown that echocardiographic screening using standard criteria adds sensitivity and precision to the diagnosis, particularly in asymptomatic disease, providing an opportunity for longitudinal community-based research. However, researchers face major constraints in rural settings where EMF is endemic, including socioeconomic, cultural, geographical and administrative barriers. In presenting our experience we aim to describe the challenges and discuss the lessons learned while implementing community-based research in a highly endemic area in southern Mozambique, one of the poorest countries in the world. Additionally, we discuss how recent advances in medicine-such as use of point-of-care diagnostics, heart failure biomarkers and new imaging techniques-may open new possibilities for high quality research through collaborative partnerships and regional initiatives.

Comprehensive Assessment of Endomyocardial Fibrosis with Cardiac MRI: Morphology, Function, and Tissue Characterization

Endomyocardial fibrosis (EMF) affects approximately 12 million persons worldwide and is an important cause of restrictive cardiomyopathy in the developing world, with the highest prevalence reported in sub-Saharan Africa, South Asia, and South America. EMF is characterized by apical filling with fibrotic tissue of one or both ventricles, often associated with thrombus, calcification, and atrioventricular valve regurgitation, leading to typical symptoms of restrictive heart failure. Transthoracic echocardiography (TTE) is the first-line modality for assessment of EMF, basically owing to its widespread availability. However, in recent years cardiac MRI has emerged as a powerful tool for assessment of cardiac morphology and function, with higher accuracy than TTE, along with the unique advantage of being able to provide comprehensive noninvasive tissue characterization. Delayed enhancement (DE) imaging is the cornerstone of cardiac MRI tissue characterization and allows accurate identification of myocardial fibrosis, conveying valuable additional diagnostic and prognostic information. The typical DE pattern in EMF, described as the "double V" sign, consists of a three-layered pattern of normal myocardium, thickened enhanced endomyocardium, and overlying thrombus at the apex of the affected ventricle; it has excellent correlation with histopathologic findings and plays an important role in differentiating EMF from other cardiomyopathies. Conversely, fibrous tissue deposition quantified using DE imaging, when indexed to body surface area, has been shown to be a strong independent predictor of mortality. The aim of this review is to summarize state-of-the-art applications of cardiac MRI for diagnostic and prognostic assessment of patients with suspected or confirmed EMF. Online supplemental material is available for this article. ^©RSNA, 2020.

Multimodality Imaging in Restrictive Cardiomyopathies: An EACVI expert consensus document In collaboration with the "Working Group on myocardial and pericardial diseases" of the European Society of Cardiology Endorsed by The Indian Academy of Echocardiography

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

Cardiac involvement in antiphospholipid syndrome: The diagnostic role of noninvasive cardiac imaging

OBJECTIVES

The antiphospholipid syndrome (APS) is an autoimmune disorder of acquired hypercoagulability characterized by vascular thrombosis, increased pregnancy morbidity, and elevated levels of antiphospholipid antibodies. Cardiac involvement in APS may be presented as heart valve disease affecting approximately a third of patients or less frequently as intracardial thombosis, pulmonary hypertension, right or left ventricular dysfunction, micro-vascular thrombosis, coronary artery, or micro-vascular disease with overt or silent clinical presentation.

METHODS

Noninvasive cardiovascular imaging plays a crucial role in the evaluation of heart involvement in APS. Transthoracic or transoesophageal echocardiography enable early, accurate diagnosis and severity assessment of HVD as well as of ventricular dysfunction and pulmonary hypertension. Studies by echocardiography and nuclear imaging have detected abnormalities in myocardial perfusion in approximately 30% of primary APS. CT scan is the technique of choice for the assessment of pulmonary embolism and can effectively detect intracardiac thrombi. Myocardial perfusion defects have been detected by 13N-ammonia PET in 40% of APS. Cardiovascular magnetic resonance (CMR) has identified an unexpectedly high prevalence of occult myocardial scarring and endomyocardial fibrosis in APS, and is the technique of choice, if quantification of heart valve disease and stress myocardial perfusion-fibrosis is needed.

RESULTS

Noninvasive, nonradiating imaging techniques, such as echocardiography and CMR are superior to CT or nuclear techniques and are of great value for the diagnosis and follow-up of both clinically overt and silent cardiac disease in APS.

CONCLUSIONS

The high incidence of cardiac involvement in APS demands early diagnosis/treatment and multimodality cardiovascular imaging is of great importance.

Right ventricular endomyocardial fibrosis (2013 Grover Conference series)

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown origin, affecting predominantly the right side of the heart. Its highest prevalence is in poor regions of sub-Saharan Africa, where it is usually found in children and adolescents. In areas where it is endemic, EMF is a major cause of heart failure and premature death. EMF of the right ventricle has unique clinical, electrocardiographic, and echocardiographic signs. Several features of advanced disease are not fully understood, the most striking being the presence of severe ascites with little or no pedal edema. Echocardiography is the main diagnostic tool and supports management of the disease in most patients, as it allows assessment of the severity and extension of endocardial fibrosis, the quality of the right atrioventricular valve, and the presence of intracardiac thrombi. Pulmonary hypertension in the setting of right EMF is related to chronic thromboembolism, through the chronic thrombi present in the severely enlarged right atrium found in advanced disease. The management of right EMF is difficult. Treatment of symptomatic patients should be surgical. However, as the disease is usually detected in late stages, with severe and advanced lesions, surgery cannot be performed without a very high risk of death and complications. New surgical approaches addressing several components of the structural cardiac abnormalities have been attempted, with promising results. EMF remains one of the most neglected diseases worldwide, and research into its pathophysiological mechanisms will probably improve outcomes and alter the natural history of the disease. This requires improvement in the health systems in areas of endemicity as well as the design of international collaborative research projects.

Obstructive left heart disease in neonates with a "borderline" left ventricle: diagnostic challenges to choosing the best outcome

In most newborns with left heart obstruction, the choice between a single-ventricle or biventricular management pathway is clear. However, in some neonates with a "borderline" left ventricle, this decision is difficult. Existing criteria do not reliably identify neonates who will have a good long-term outlook after biventricular repair (BVR). The objective of this study was prospective assessment of the outcome after BVR for newborns in whom the left ventricle (LV) was considered "borderline" by an expert group. This study was a prospective follow-up evaluation of neonates with obstructive left heart disease related to a "borderline" LV who underwent biventricular management between January 2005 and April 2011. Of 154 neonates who required intervention for left heart obstruction, 13 (7.8 %) met the echocardiographic (echo) inclusion criteria. At the first and last echo, the z-scores were respectively -1.76 ± 1.37 and -0.66 ± 1.47 (p = 0.013) for the mitral valve, -1.02 ± 1.57 and -0.23 ± 1.78 (p = 0.056) for the aortic valve, and 13.77 ± 5.8 and 20.85 ± 8.9 ml/m(2) (p = 0.006) for the LV end-diastolic volume. At this writing, all 12 survivors are clinically well. However, LV diastolic dysfunction and pulmonary artery hypertension was present in 5 (36 %) of 12 patients. Endocardial fibroelastosis (EFE) was detected in five patients at the last follow-up echo, but only in two patients preoperatively. Cardiac magnetic resonance imaging did not confirm EFE in any of assessed patients. The study authors could not reliably predict the outcome after BVR for neonates with left heart obstruction and a "borderline" LV. The presence of EFE with consequent diastolic dysfunction is more important than LV volume in determining the outcome. Prospective identification of EFE remains challenging.

Recent advances in the epidemiology, diagnosis and treatment of endomyocardial fibrosis in Africa

Endomyocardial fibrosis (EMF) continues to be an important and disabling disease in many parts of Africa, although its prevalence has declined in some parts of the continent. Increased access to medical care in general and increased availability of echocardiography in some parts of the continent have led to recognition of the disease in areas in which the disease had not been previously reported, and this has given new insights into its natural history. However, the early manifestations of EMF continue to elude clinicians and researchers, and no progress has been made in defining its aetiology. Advances have, however, been made in establishing the epidemiology and improving clinical diagnosis and management, through modern medical therapy and improved surgical techniques. Research is still required to define clinical, biological and echocardiographic markers of early stages of EMF, so that advances in the knowledge of its pathogenesis and pathophysiology can be made. This will hopefully determine preventive measures and avoid the burden of this debilitating condition in this continent.

Endomyocardial fibrosis: A form of endemic restrictive cardiomyopathy

Endomyocardial fibrosis is a form of endemic restrictive cardiomyopathy that affects mainly children and adolescents, and is geographically restricted to some poor areas of Africa, Latin America and Asia. It is a condition with high morbidity and mortality, for which no effective therapy is available. Although several hypotheses have been proposed as triggers or causal factors for the disease, none are able to explain the occurrence of the disease worldwide. In endemic areas of Africa endomyocardial fibrosis is as common a cause of heart failure as rheumatic heart disease, accounting for up to 20% of cases of heart failure and imposes a considerable burden to the communities and the health systems. However, due to lack of resources for research in these areas, the exact epidemiology, etiology and pathogenesis remain unknown, and the natural history is incompletely understood. We here review the main aspects of epidemiology, natural history, clinical picture and management of endomyocardial fibrosis, proposing new ways to increase research into this challenging and neglected cardiovascular disease.

Late gadolinium enhancement magnetic resonance imaging in the diagnosis and prognosis of endomyocardial fibrosis patients

BACKGROUND

Endocardial fibrous tissue (FT) deposition is a hallmark of endomyocardial fibrosis (EMF). Echocardiography is a first-line and the standard technique for the diagnosis of this disease. Although late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) allows FT characterization, its role in the diagnosis and prognosis of EMF has not been investigated.

METHODS AND RESULTS

Thirty-six patients (29 women; age, 54±12 years) with EMF diagnosis after clinical evaluation and comprehensive 2-dimensional Doppler echocardiography underwent cine-CMR for assessing ventricular volumes, ejection fraction and mass, and LGE-CMR for FT characterization and quantification. Indexed FT volume (FT/body surface area) was calculated after planimetry of the 8 to 12 slices obtained in the short-axis view at end-diastole (mL/m(2)). Surgical resection of FT was performed in 16 patients. In all patients, areas of LGE were confined to the endocardium, frequently as a continuous streak from the inflow tract extending to the apex, where it was usually most prominent. There was a relation between increased FT/body surface area and worse New York Heart Association functional class and with increased probability of surgery (P<0.05). The histopathologic examination of resected FT showed typical features of EMF with extensive endocardial fibrous thickening, proliferation of small vessels, and scarce inflammatory infiltrate. In multivariate analysis, the patients with FT/body surface area >19 mL/m(2) had an increased mortality rate, with a relative risk of 10.8.

CONCLUSIONS

Our study provides evidence that LGE-CMR is useful in the diagnosis and prognosis of EMF through quantification of the typical pattern of FT deposition.

Left ventricular diastolic heart failure in teenagers who underwent balloon aortic valvuloplasty in early infancy

We report 4 teenage patients who, after successful palliation of severe aortic valve stenosis by balloon aortic valvuloplasty in early infancy, presented within the previous 3 years with significant left ventricular (LV) diastolic heart failure. All patients had remained asymptomatic until their teenage years and had normal or hyperdynamic LV systolic function on presentation, with limited residual aortic valve stenosis and regurgitation. All underwent echocardiography, cardiac catheterization, and cardiac magnetic resonance evaluation. One notable common feature in the 4 patients was the presence of a confluent layer of LV subendocardial hyperenhancement demonstrated by late gadolinium enhancement technique. Histopathology was available for 2 patients, which documented significant LV endocardial fibroelastosis. One patient who underwent endocardial fibroelastosis resection in conjunction with aortic valve replacement had late clinical improvement. In conclusion, this group of patients may represent an important emerging clinical entity and merits close clinical surveillance, with prospective assessment of diastolic function.

Cardiovascular magnetic resonance of cardiomyopathies. Curr Cardiol Rep. 2009;11:61-69. [PMID: 19091177 DOI: 10.1007/s11886-009-0010-3]

Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with architectural abnormalities and mechanical dysfunction. Recent advances in our understanding of the genetics, pathophysiology, and natural history of these conditions has resulted in better diagnosis and management, leading to improvements in mortality. Major developments in imaging techniques, in particular contrast-enhanced MRI, now permit in vivo tissue characterization of the myocardium. Through defining disease severity, etiology, and to some extent in risk stratification, routine cardiovascular magnetic resonance evaluation of this group of patients provides essential information required in everyday clinical practice.

Biventricular apical thrombi demonstrated by contrast-enhanced cardiac MRI following anteroapical STEMI and unsuccessful reperfusion therapy

Contrast-enhanced cardiac magnetic resonance imaging can define the territory and extent of myocardial infarction from patterns of late gadolinium enhancement. Following failure to reperfuse with thrombolytic therapy, a case of myocardial infarction is described in which ongoing symptoms and an electrocardiogram change led to a diagnostic dilemma. Cardiac magnetic resonance imaging confirmed an apical infarction, an aneurysm and acute pericarditis. In addition, late gadolinium enhancement unexpectedly revealed the presence of biventricular apical thrombi. The prevalence of cardiac thrombi and pulmonary emboli may be greater than generally appreciated.

[Necrotic myocarditis in acute eosinophilic lymphoblastic leukaemia]

INTRODUCTION

Hypereosinophilia can cause severe cardiac complications. The association between an acute lymphoblastic leukemia and hypereosinophilia was rare. We report a case of a 29-year-old man who presented a heart failure secondary to necrotic myocarditis related to an acute eosinophilic lymphoblastic leukaemia.

EXEGESIS

The patient developed a heart failure and secondary a cardio-embolic stroke, due to a large mobile left ventricle thrombosis. His peripheral blood showed a total white count of 28,500 leucocytes/mm3 with 18,800 eosinophils/mm3. The myelogram cytology showed precursor B-cell acute lymphoblastic leukaemia with hypereosinophilia.

CONCLUSION

The possibility of the rapid emergence of cardiac lesions in hypereosinophilic syndromes warrants very close physician vigilance. An Echocardiography and MRI performed at the early stage and in the follow-up allow to detect and to manage these cardiac disorders.