Trombo biventricular e fibrose endomiocárdica na síndrome antifosfolípide

Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review

Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.

Case Report: An Unusual Case of Biventricular Thrombosis in a COVID-19 Patient With Ischemic Dilated Cardiomyopathy: Assessment of Mass Mobility and Embolic Risk by Tissue Doppler Imaging

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein binds to angiotensin-converting enzyme 2 (ACE2) receptor on vascular cells. As a consequence, patients with COVID-19 have an increased incidence of thromboembolic complications of the SARS-CoV-2 infection and subsequent endothelial cell damage with consequence of development of systemic vasculitis and diffuse intravascular coagulation. The present case describes a COVID-19 female patient with ischemic dilated cardiomyopathy, who presented with congestive heart failure and echocardiographic evidence of biventricular apical thrombi. The peak antegrade longitudinal velocity (Va) of each thrombotic mass was measured by pulsed wave tissue Doppler imaging (PW-TDI). Both left ventricular and right ventricular apical thrombi were found with a TDI-derived mass peak Va < 10 cm/s. There was no clinical evidence of neither systemic nor pulmonary embolization, probably due to the hypomobility of both left and right ventricular masses.

Unexpected death due to a biventricular thrombosis: Case report and review of literature

Cardiac thrombosis is an unusual condition characterised by the formation of a clot in the heart chambers. Biventricular thrombosis with obstruction of blood flow and fatal cardiogenic shock is anecdotal. This report describes a rare biventricular thrombosis in an elderly woman without known risk factors which was diagnosed at autopsy. A complete autopsy is essential to ascertain the cause of death, especially in complex cases with little medical history. We suggest a possible explanation for the pathophysiological mechanism.

Cardiovascular magnetic resonance detects silent heart disease missed by echocardiography in systemic lupus erythematosus

Background

Accurate diagnosis of cardiovascular involvement in systemic lupus erythematosus (SLE) remains challenging, due to limitations of echocardiography. We hypothesized that cardiovascular magnetic resonance can detect cardiac lesions missed by echocardiography in SLE patients with atypical symptoms.

Aim

To use cardiovascular magnetic resonance in SLE patients with atypical symptoms and investigate the possibility of silent heart disease, missed by echocardiography.

Patients/methods

From 2005 to 2015, 80 SLE patients with atypical cardiac symptoms/signs (fatigue, mild shortness of breath, early repolarization and sinus tachycardia) aged 37 ± 6 years (72 women/8 men), with normal echocardiography, were evaluated using a 1.5 T system. Left and right ventricular ejection fractions, T2 ratio (oedema imaging) and late gadolinium enhancement (fibrosis imaging) were assessed. Acute and chronic lesions were defined as late gadolinium enhancement-positive plus T2>2 and T2<2, respectively. Lesions were characterized according to late gadolinium enhancement patterns as: diffuse subendocardial, subepicardial and subendocardial/transmural, due to vasculitis, myocarditis and myocardial infarction, respectively.

Results

Abnormal cardiovascular magnetic resonance findings were identified in 22/80 (27.5%) of SLE patients with normal echocardiography, including 4/22 with recent silent myocarditis, 5/22 with past myocarditis (subepicardial scar in inferolateral wall), 9/22 with past myocardial infarction (six inferior and three anterior subendocardial infarction) and 4/22 with diffuse subendocardial fibrosis due to vasculitis. No correlation between cardiovascular magnetic resonance findings and inflammatory indices was identified.

Conclusions

Cardiovascular magnetic resonance in SLE patients with atypical cardiac symptoms/signs and normal echocardiography can assess occult cardiac lesions including myocarditis, myocardial infarction and vasculitis that may influence both rheumatic and cardiac treatment.

A case of biventricular thrombi in a patient with dilated cardiomyopathy: Utility of multimodality imaging for diagnosis and management of treatment strategy

A 54-year-old man was transferred to our hospital due to congestive heart failure and left ventricular thrombi. Transthoracic echocardiography (TTE) showed mobile "ball-like" not only left ventricular but also right ventricular thrombi associated with severe impaired left and right ventricular function. Contrast-enhanced computed tomography (CT) and cardiac magnetic resonance imaging (MRI) also detected biventricular apical thrombi complicated with right renal infarction. Coronary angiography showed non-significant stenosis. Due to the mobility of thrombi and complication of systemic infarction, the surgical transatrial video-assisted removal of biventricular thrombi was performed and postoperative course has been uneventful over a period of 6 months. Endomyocardial biopsy performed during an operation showed no specific findings such as endomyocarditis, indicating the diagnosis of dilated cardiomyopathy (DCM). This is a rare case of DCM complicated with biventricular apical thrombi detected clearly by multimodality imaging such as TTE, contrast-enhanced CT and cardiac MRI, and surgical removal was performed successfully. <Learning objective: The incidence of biventricular thrombi is rare and has been reported to be associated with coagulation abnormality and severe ventricular dysfunction. The detection of ventricular thrombi using echocardiography is sometimes difficult, and treatment strategy often becomes a major topic of debate. The usefulness of multimodality imaging for the detection of ventricular thrombi leads to accurate diagnosis and provides helpful information regarding the selection of appropriate treatment.>.

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.