Endomyocardial fibrosis: a tragic conundrum or a mere negligence?

Often termed as 'vanishing mystery' epidemiologically, endomyocardial fibrosis (EMF) continues to be the the most common cause of restrictive cardiomyopathy in Africa and some parts of the Indian subcontinent, where it is considered a significant public health problem. On the other hand, in developed countries, it is considered a rare phenomenon. This entity is considered incurable due to lack of targeted therapies, even after 75 years since its discovery. The authors describe here a case of an Indian male, in his early 30s who presented with complaints of dyspnoea on minimal daily activities, swelling of both legs and abdominal fullness for 3 months. The clinical features were suggestive of isolated right heart failure. He was diagnosed with EMF on echocardiography and the findings were confirmed on cardiac MRI. The patient has progressed to develop biventricular dysfunction and is being managed symptomatically with diuretics due to unavailability of targeted treatment options at present.

Endomyocardial fibrosis with ischaemic stroke

A Caucasian man in his mid-50s presented to the emergency department with sudden onset right-sided weakness and dysarthria. CT angiogram demonstrated a small volume of left middle cerebral artery territory infarction after which the patient underwent successful thrombolysis. Initial ECG showed diffuse T wave inversion. He was admitted to an acute stroke ward where 72 hours of telemetry demonstrated normal sinus rhythm without arrhythmia. Transthoracic echocardiogram showed a reduced ejection fraction of 47% in the absence of any regional wall motion abnormality. An echogenic mass was noted in the apical inferior septal wall. Cardiac MRI demonstrated circumferential mid to apical endocardial thickening with characteristic appearances consistent with endomyocardial fibrosis (EMF). Furthermore, a visible hypointensity in the apex confirmed left ventricular thrombus adherent to the area of EMF. The patient was started on anticoagulation and heart failure therapy. He has recovered from the ischaemic stroke and is currently under outpatient surveillance.

Endomyocardial fibrosis and apical calcification: A case report with unusual presentations of apical hypertrophic cardiomyopathy

RATIONALE

Apical hypertrophic cardiomyopathy (ApHCM) is a phenotypic variant of hypertrophic cardiomyopathy. Endomyocardial fibrosis and endocardial calcification are especially rare in ApHCM.

PATIENT CONCERNS

The main symptoms was chest tightness, palpitation, shortness of breath, and fatigue. Echocardiography and imaging examinations found apical hypertrophy along with endocardial calcification and endomyocardial fibrosis. Abnormal structural changes led to thrombosis and made the left ventricle a flat shape resembling an "apple."

DIAGNOSES

The typical presentations, hypertrophic apex on echocardiography and an elevated N-terminal pro-brain natriuretic peptide level indicated the diagnosis of ApHCM and heart failure with preserved ejection fraction.

INTERVENTIONS

Optimal medical therapy including the administration of ApHCM, heart failure and atrial fibrillation to improve symptoms and life quality.

OUTCOMES

Since discharge, the patient could perform normal daily activities and had no discomfort based on the optimal medical therapy.

LESSONS

We report a ApHCM patients with unusual presentations of endomyocardial fibrosis and apical calcification. This case highlights the importance of understanding the specific pathological changes of ApHCM for treatment and prognosis.

Left ventricle endomyocardial fibrosis: a case report

BACKGROUND

Endomyocardial fibrosis is a grim disease. It is the most common restrictive cardiomyopathy worldwide, but the exact etiology and pathogenesis both remain unknown. Endomyocardial fibrosis is recurrently associated with chronic eosinophilia and probable dietary, environmental, and infectious factors, which contribute not only to the onset of the disease (an inflammatory process) but also to its progression and maintenance (endomyocardial damage and scar formation). The trademark of the disease is the fibrotic obliteration of the affected ventricle. The combination of such processes produces focal or diffuse endocardial thickening and fibrosis, which leads to restrictive physiology. Endomyocardial fibrosis affects the apices of the right and the left ventricle in around 50% of cases and most often extends to the posterior leaflet of the mitral valve. Sometimes it involves the papillary muscle and chordae tendineae, causing atrioventricular valve dysfunction. The fibrosis does not affect extracardiac organs. This cardiomyopathy is most recurrent in tropical areas of the world.

CASE PRESENTATION

A 67-year-old Black male with past medical history of schistosomiasis infection in childhood presented with progressive dyspnea, lower extremity edema, and weakness for 2 years. He was diagnosed with endomyocardial fibrosis. The echocardiogram showed an increased thickness in the septum (17 mm) and free left ventricular wall (15 mm), obliteration of the left ventricular apex and inflow tract, and mitral valve regurgitation. Cardiac magnetic resonance imaging revealed apical left ventricle wall thickening with left ventricular apical obliteration associated with enlargement of the respective atrium. Delayed enhancement imaging showed endomyocardium enhancement involving left ventricular apex, mitral valve regurgitation due to annulus dilation, and a thrombus at left ventricular apex. He underwent open heart surgery with mitral valve replacement, endocardial decortication, endomyocardiectomy, and two-vessel coronary artery bypass grafting as preoperative coronary angiogram showed mild right coronary artery and proximal left anterior descending artery severe lesions. Postoperative course was uncomplicated, and he was discharged successfully from the hospital. Six months after surgery, he was New York Heart Association functional class I.

CONCLUSION

The purpose of this case report is to illustrate the aspects of endomyocardial fibrosis by reporting a case of this entity. In conclusion, progress in imaging techniques and treatment in a reference institution for cardiac diseases contribute to earlier diagnosis and survival in patients with endomyocardial fibrosis.

Intracardiac mass revealing a rare form of cardiomyopathy

We present the case of a woman with a 2-month history of exertional dyspnoea and fatigue in which echocardiography revealed a cavity-obliterating right ventricular mass. Further imaging evaluation using cardiac magnetic resonance showed a thrombotic mass as well as diffuse myocardial oedema and endomyocardial fibrosis (EMF) that involved both ventricles. In the absence of any other cause (including peripheral eosinophilia), the diagnosis of idiopathic EMF was established. This case highlights this uncommon disease in non-tropical areas.

An unusual tropical endomyocardial fibrosis: a case report

Tropical endomyocardial fibrosis (TEF) is a rare condition that occurs primarily in tropical countries, leading to a severe heart failure with heart restrictive filling patterns. Eosinophilia appears to be a trigger leading to the development of the disease; thus, numerous etiologic factors accompanied by eosinophilia have been postulated, although none have been confirmed. The massively calcified form of TEF is exceptional and easily diagnosed by multimodal imaging; but it is a very rare condition with high surgical challenge. the best prevention remains the testing and treatment of parasitic infections frequently encountered in these countries.

Effects of progranulin on the pathological conditions in experimental myocardial infarction model

Progranulin is a secreted growth factor associated with multiple physiological functions in ischemic pathophysiology. However, it is still not fully understood how progranulin is involved in ischemic lesion and cardiac remodeling after myocardial infarction (MI). In this study, we investigated the effects of progranulin on myocardial ischemia and reperfusion injury. We investigated progranulin expression using Western blotting and immunostaining after permanent left coronary artery (LCA) occlusion in mice. Infarct size and the number of infiltrating neutrophils were measured 24 h after permanent LCA occlusion. Recombinant mouse progranulin was administered before LCA occlusion. In addition, we evaluated cardiac function using cardiac catheterization and echocardiography, and fibrosis size by Masson's trichrome staining after myocardial ischemia/reperfusion in rabbits. Recombinant human progranulin was administered immediately after induction of reperfusion. Progranulin expression increased in the myocardial ischemic area 1, 3, and 5 days after permanent LCA occlusion in mice. The administration of recombinant mouse progranulin significantly attenuated infarct size and infiltrating neutrophils 24 h after permanent LCA occlusion in mice. We also found that administration of recombinant human progranulin ameliorated the deterioration of cardiac dysfunction and fibrosis after myocardial ischemia/reperfusion in rabbits. These findings suggest that progranulin may protect myocardial ischemia/reperfusion injury.

Apical hypertrophic cardiomyopathy with apical endomyocardial fibrosis and calcification: Two case reports

RATIONALE

Apical hypertrophic cardiomyopathy (AHCM) is a rare form of hypertrophic cardiomyopathy which affects predominantly the apex of the left ventricle. Generally, left ventricular enlargement is not present in AHCM; additionally, endomyocardial fibrosis, and calcification are also rare.

PATIENT CONCERNS

A 61-year-old female (Case 1) and a 60-year-old female (Case 2) both presented with the symptoms of atypical chest pain, dyspnoea, exercise intolerance, palpitations.

DIAGNOSIS

Magnetic resonance and single-photon emission computed tomography (SPECT) revealed apical hypertrophic cardiomyopathy. Furthermore, 2D-transthoracic echocardiogram showed left atrium and ventricular enlargement, as well as endomyocardial fibrosis and calcification. Based on these findings, the patients were diagnosed with AHCM.

INTERVENTIONS

Both the patients were treated with ACEI, metoprolol, and aspirin. Additionally, both these patient underwent genetic test.

OUTCOMES

The results of the genetic test of the 2 cases for hypertrophic cardiomyopathy (HCM) were negative. However, the gene mutation for dilated cardiomyopathy (TMPO) was detected in one of the cases. No change in condition during follow-up.

LESSONS

In past reports, Apical hypertrophic cardiomyopathy has been shown to have a benign prognosis. But in this case report, the imaging studies of the 2 patients suggest a poor prognosis. Furthermore, diagnosing cardiomyopathy should require multimodality imaging examinations to rule out differential diagnoses.

Echocardiographic, chest X-ray and electrocardiogram findings in children presenting with heart failure to a Ugandan paediatric ward

The aim of this study was to describe the aetiology of congestive cardiac failure (CCF) in children with suspected structural abnormalities presenting to a regional hospital in southwestern Uganda. The method used was a prospective descriptive study of successive admissions of children with persistent cardiac signs after routine treatment of CCF. Children with severe anaemia (haemoglobin [Hb]<7 g/dL), pneumonia, sepsis or severe malnutrition were excluded. Chest X-ray, electrocardiogram and echocardiography data were validated by a paediatric cardiologist and radiologist at the Bristol Royal Hospital for Children, UK. A cohort of 58 patients was identified. The aetiology of heart failure in this cohort ( n = 58) was due to congenital heart disease (35%), renal hypertensive disease (26%), rheumatic heart disease (17%), cardiomyopathies (12%), endomyocardial fibrosis (7%) and tamponade (3%). In conclusion, this study confirmed the ongoing prevalence of congenital heart disease, rheumatic heart disease and endomyocardial fibrosis in this area. The cardiac effect of renal hypertension was a new and significant finding.

A prominent 'A' notch in the pulmonary valve M mode-one more cause of the same

The M mode echocardiogram is not the main priority, during routine echocardiographic evaluation now-a-days. However, there are still a few classical conditions where this remains instructive and educative. One such situation is the presence of an 'a' wave in the pulmonary valve M mode tracing in normals and it's absence in pulmonary hypertension. In valvular pulmonary stenosis we expect a deeper 'a' wave. We describe one more cause of a prominent 'a' wave in the pulmonary valve M mode. We describe this in a common tropical disease, endemic to Kerala.

Endomyocardial fibrosis associated with Schistosoma haematobium infection

Endomyocardial fibrosis (EMF) is a form of restrictive cardiomyopathy common in the tropics and subtropics. The aetiology of EMF is unknown but helminth infestations such as schistosomiasis have been implicated. Two boys aged 8 and 10 years with EMF associated with Schistosoma haematobium, are described. The schistosomes in both cases may have been acquired from contact with contaminated water collected and stored in containers and subsequently used for bathing. Both patients were managed conservatively. Overall prognosis of EMF is poor and this report emphasizes the importance of public health interventions in the control of schistosomiasis.

Myocardial fibrosis detected by cardiac CT predicts ventricular fibrillation/ventricular tachycardia events in patients with hypertrophic cardiomyopathy

BACKGROUND

Myocardial fibrosis (MF) occurs in up to 80% of subjects with asymptomatic or mildly symptomatic hypertrophic cardiomyopathy (HCM) and can constitute an arrhythmogenic substrate for re-entrant, life-threatening ventricular arrhythmias in predisposed persons.

OBJECTIVE

The aim was to investigate whether MF detected by delayed enhancement cardiac CT is predictive of ventricular tachycardia (VT) and fibrillation (VF) that require appropriate therapy by an implantable cardioverter defibrillator (ICD) in patients with HCM.

METHODS

Twenty-six patients with HCM with previously (for at least 1 year) implanted ICD underwent MF evaluation by cardiac CT. MF was quantified by myocardial delayed enhanced cardiac CT. Data on ICD firing were recorded every 3 months after ICD implantation. Risk factors for sudden cardiac death in patients with HCM were evaluated in all patients.

RESULTS

MF was present in 25 of 26 patients (96%) with mean fibrosis mass of 20.5 ± 15.8 g. Patients with appropriate ICD shocks for VF/VT had significantly greater MF mass than patients without (29.10 ± 19.13 g vs 13.57 ± 8.31 g; P = .01). For a MF mass of at least 18 g, sensitivity and specificity for appropriate ICD firing were 73% (95% CI, 49%-88%) and 71% (95% CI, 56%-81%), respectively. Kaplan-Meier curves indicated a significantly greater VF/VT event rate in patients with MF mass ≥18 g than in patients with MF <18 g (P = .02). In the Cox regression analysis, the amount of MF was independently associated with VF/VT in ICD-stored electrograms.

CONCLUSION

The mass of MF detected by cardiac CT in patients with HCM at high risk of sudden death was associated with appropriate ICD firings.

Right ventricular endomyocardial fibrosis

Endomyocardial fibrosis is a variety of restrictive cardiomyopathy, in which endocardium of one or both ventricles is thickened markedly with involvement of underlying myocardium. Partial obliteration of ventricular cavities by fibrous tissue and thrombus causes diastolic dysfunction with increased resistance to ventricular filling. Systolic function is well preserved till late stages. Biventricular or isolated left ventricular involvement is common. Isolated right ventricular involvement is relatively uncommon. Case reports on endomyocardial fibrosis have declined in literature. In India, endomyocardial fibrosis is mainly reported from Kerala. A case of right ventricular endomyocardial fibrosis from West Bengal is reported here. Isolated right sided endomyocardial fibrosis, massive right atrial enlargement, complete disorganization of tricuspid valve, massive pericardial effusion, normal absolute eosinophil count and its sporadic occurrence outside 15 degrees of the equatorial belt were interesting features in this case of endomyocardial fibrosis. X-ray features were typical of pericardial effusion masking underlying endomyocardial fibrosis. Endomyocardial fibrosis is a neglected research field. It needs more attention from biomedical researchers.

["African sickness" and the heart: the mystery of endomyocardial fibrosis]

The epidemic of cardiovascular disease is a global phenomenon and the magnitude of its increase in incidence and prevalence in low-income countries has potentially major implications for those high-income countries that characterize the developed world. The "epidemiologic transition" provides a useful framework for understanding changes in the patterns of disease as a result of socioeconomic and demographic developments. According to the migratory flow, the burden of African immigrants in Italy is rising, and there is a need to re-assess the clinical management of anything but obsolete western cardiovascular disorders also delving into the rare tropical neglected diseases. Rheumatic fever and tropical cardiac diseases, such as endomyocardial fibrosis in Africa and Chagas disease in Latin America, require a human resource framework to direct into research and intervention programs. This review will focus upon endomyocardial fibrosis, by far the most common type of restrictive cardiomyopathy worldwide, still an unsolved puzzle from a pathophysiological point of view and in need of more attention from the international community of cardiologists. In this paper the data from the literature are implemented by our personal experience at the St. Raphael of St. Francis Hospital-Nsambya and the Ugandan Heart Institute of Kampala, the capital town of Uganda.

An unusual form of intracardiac thrombosis and fibrinolytic process in a child with dilated cardiomyopathy

A twelve-year-old girl presented with tachypnoea, cough and fatigue existing for 3 weeks, which subsequently proved to be caused by dilated cardiomyopathy. Echocardiography showed an echogenic mass with echolucent centre attached to the inferolateral wall of the left ventricle. There was prominent systolic dysfunction. Dilated cardiomyopathy is associated with an increased risk of intracardiac thrombosis. The intracardiac thrombi usually appear as a solid mass on the echocardiogram. The case was presented to emphasize the unususal echocardiographic appearance of an intracardiac thrombus associated with dilated cardiomyopathy.

Endomyocardial fibrosis: an under-diagnosed cause of cardiomyopathy in Sudanese children

Endomyocardial fibrosis (EMF) is a tropical cardiomyopathy reported in many tropical countries. Patients were seen at the Children's Hospital-Khartoum, Sudan during September 2007-08 where cardiac evaluation was done. Six patients were identified (18% of all children with cardiomyopathy); all were males aged 8-17 years. All patients presented with abdominal distention, stunted growth, raised jugular venous pressure, ascites and hepatosplenomegaly. Electrocardiogram abnormalities included atrial fibrillation, first and third degree AV block and tall P wave. Echocardiography revealed huge right atrium dilatation and right ventricle apex obliteration by fibrous tissue. One patient had left-side affection with moderate mitral regurgitation. Eosinophilia was present in three patients. Two patients received antituberculosis drugs with no improvement, two had history of treated bilharziasis and two had been labeled as having Ebstein disease. EMF is an important cause of cardiomyopathy in Sudan that is often misdiagnosed. Clinical and echocardiographic examinations can lead to the correct diagnosis.

Endomyocardial fibrosis

We present a case report of a 26-year-old male from Bulandsahar, India. The patient presented with right heart failure. Evaluation revealed peripheral eosinophilia. An echocardiogram and MRI showed biventricular hypertrophy with obliteration of the ventricular apices, typical of endomyocardial fibrosis. This condition is rare in Bulandsahar, India.

[Endomyocardial disease: a case report]

Endomyocardial disease is a form of restrictive cardiomyopathy, of unknown etiology, which occurs most commonly in tropical and subtropical areas. It is characterized by the formation of endomyocardial fibrosis of the apical and subvalvular regions of one or both ventricles. A 29-year-old male patient was admitted with restrictive cardiomyopathy and decompensated heart failure. Telecardiography showed cardiomegaly and right pleural effusion. Transthoracic echocardiography revealed preserved left ventricular systolic functions, biatrial dilatation, apical obliteration of both ventricles, increased endocardial echoreflectivity, and pericardial effusion. The right ventricular outflow tract was dilated. There was no endocardial thickening in this region. Doppler examination showed grade 3 mitral and tricuspid regurgitation. Ventriculograms showed apical obliteration of both ventricles, marked decrease in the size of the right ventricular cavity, significant dilatation of the right ventricular outflow tract and both atria, and severe mitral and tricuspid regurgitation. Laboratory findings showed no hypereosinophilia. Hepatic congestion, splenomegaly, and ascites were noted on abdominal ultrasonography. Following cardiac catheterization, the patient was placed on the waiting list for cardiac transplantation.

A population study of endomyocardial fibrosis in a rural area of Mozambique

BACKGROUND

Endomyocardial fibrosis is the most common restrictive cardiomyopathy worldwide. It has no specific treatment and carries a poor prognosis, since most patients present with advanced heart failure. On the basis of clinical series, regional variations in distribution have been reported within several countries in Africa, Asia, and South America, but large-scale data are lacking on the epidemiologic features and early stages of the disease.

METHODS

We used transthoracic echocardiography to determine the prevalence of endomyocardial fibrosis in a rural area of Mozambique. We screened a random sample of 1063 subjects of all age groups selected by clustering. Major and minor diagnostic criteria were defined, and a severity score was developed and applied. Cases were classified according to the distribution and severity of the lesions in the heart.

RESULTS

The estimated overall prevalence of endomyocardial fibrosis was 19.8%, or 211 of 1063 subjects (95% confidence interval [CI], 17.4 to 22.2). The prevalence was highest among persons 10 to 19 years of age (28.1%, or 73 of 260 subjects [95% CI, 22.6 to 33.6]) and was higher among male than among female subjects (23.0% vs. 17.5%, P=0.03). The most common form was biventricular endomyocardial fibrosis (a prevalence of 55.5%, or 117 of 211 subjects [95% CI, 48.8 to 62.2]), followed by right-sided endomyocardial fibrosis (a prevalence of 28.0%, or 59 of 211 subjects [95% CI, 21.9 to 34.1]). Most affected subjects had mild-to-moderate structural and functional echocardiographic abnormalities. Only 48 persons with endomyocardial fibrosis (22.7%) were symptomatic. The frequency of familial occurrence was high.

CONCLUSIONS

Endomyocardial fibrosis is common in a rural area of Mozambique. By using echocardiography, we were able to detect early, asymptomatic stages of the disease. These findings may aid in the study of the pathogenesis of the disease and in the development of new management strategies.

Patchy myocardial fibrosis 20 years after radiation therapy

We describe a case of a young woman diagnosed with Ewings sarcoma at age 8 and treated with adriamycin and radiation therapy. Twenty years later the patient has a cardiomyopathy and a focal area of patchy infiltration of fibrotic tissue along the left ventricle and atrium. Although fibrosis due to radiation exposure has been demonstrated on biopsy and autopsy studies, we are not aware of previous reports of echocardiographic demonstration of this finding. The most likely explanation for the fibrosis location is the left posterolateral direction of the radiation beam.

Non-invasive quantitation of myocardial fibrosis using combined tissue harmonic imaging and integrated backscatter analysis in dilated cardiomyopathy

BACKGROUND

Echocardiographic modalities have challenged the myocardial tissue characterization, but this reliability has not reached to the clinical use. This study investigated whether combined tissue harmonic imaging (THI) and integrated backscatter analysis (IB) provide the reliable and quantitative information about myocardial fibrosis in idiopathic dilated cardiomyopathy (DCM) in comparison with myocardial biopsy findings.

METHODS

We studied 56 patients with DCM. All patients underwent left ventricular endomyocardial biopsy and IB with fundamental imaging (FI) and THI.

RESULTS

In patients with good echocardiographic image quality, excellent correlations between the percentage of area occupied by myocardial fibrosis (% fibrosis) and the mean of integrated backscatter during a cardiac cycle (m-IB) measured with FI or THI were seen, and the correlation was closer with THI compared with FI. While in patients with poor image quality the correlation between m-IB and % fibrosis was only modest with FI, but the correlation was excellent with THI. Four cut-off values of m-IB with THI obtained from receiver operating characteristic curve discriminated between % fibrosis of more and less than 25, 30, 35, and 40% with high sensitivity and specificity. Multivariate analysis revealed that m-IB with THI was an independent predictor for discrimination of the severity of myocardial fibrosis.

CONCLUSION

Combined IB and THI are a clinically applicable method and may be an alternative to myocardial biopsy in evaluating quantitatively myocardial fibrosis in DCM.

Relation Between Flow Reserve Capacity of Penetrating Intramyocardial Coronary Arteries and Myocardial Fibrosis in Hypertension: Study Using Transthoracic Doppler Echocardiography

OBJECTIVE

The purpose of this study was to compare coronary flow reserve (CFR) capacity of penetrating intramyocardial coronary artery (PICA) using transthoracic Doppler echocardiography and biochemical marker of myocardial fibrosis in hypertension (HTN).

METHODS

In 58 patients (male:female ratio = 31:27; mean age 47 +/- 9 years) with chest pain and normal coronary angiogram findings, the width of color Doppler signal and peak diastolic velocity of PICA flow were measured in the myocardium just beneath the apical impulse window using transthoracic Doppler echocardiography. PICA-CFR and PICA-width ratio were calculated as the ratio of hyperemic to baseline peak diastolic velocity and as the ratio of hyperemic to baseline width after the adenosine infusion (140 mug/kg/min), respectively. Serum carboxy-terminal propeptide of procollagen type I, as a biochemical marker, was measured and patients were divided into 3 groups: 19 with HTN and PICA-CFR less than 2.0 (group A); 23 with HTN and PICA-CFR of 2.0 or more (group B); and 16 who were normotensive with PICA-CFR of 2.0 or more (group C).

RESULTS

Baseline peak diastolic velocity for group A was higher than the other two groups (P < .005 vs groups B and C). PICA-width ratio was higher than the other two groups (P < .005 vs groups B and C). Serum propeptide of type I was 137.1 +/- 16.6 ng/mL in group A, 96.2 +/- 13.7 ng/mL in group B, and 78.8 +/- 11.2 ng/mL in group C (P < .0001 vs group B and group C). PICA-CFR was closely related to serum propeptide of type I (P < .001, r = -0.723).

CONCLUSION

The impaired PICA-CFR is related to myocardial fibrosis in patients with HTN, chest pain, and normal coronary angiogram results.

Endomiocardiofibrose biventricular associada à amiloidose renal

Endomyocardiofibrosis is a restrictive cardiomyopathy characterized by fibrotic involvement of the endocardium and adjacent myocardium, and by diastolic dysfunction caused by changes in distensibility making ventricular filling inadequate while preserving the systolic function. Clinically, it appears as heart failure, but etiological symptomatic discernment, suspicion and a clinical examination would be necessary in order to make a correct etiological diagnosis. The case of a patient with biventricular endomyocardial fibrosis associated with renal amyloidosis is presented.

Porcelain heart: a case of massive myocardial calcification

Reports of massive myocardial calcification are limited mainly to case reports and this type intracardiac calcifications have been usually identified postmortem. We present a very interesting case of massive calcification of the left ventricular myocardium, interventricular and interatrial septae causing restrictive physiology and coronary artery obstruction in a 46-year-old Turkish woman. The diagnosis of myocardial calcification was suspected from chest X-ray and confirmed with computerized tomography and cardiac catheterization. The findings of the chest computed tomography were very similar to those previously reported cases of endomyocardial fibrosis (EMF) with massive calcification of the left ventricle.

Two cases of endomyocardial disease with hypereosinophilia in Turkey

Endomyocardial disease is characterized by fibrothrombotic thickening of apical endocardium and subvalvular regions of atrioventricular valves. The disease is uncommon in Turkey. In this report two cases of endomyocardial disease with hypereosinophilia which were medically managed are presented.

Clinico-pathological evaluation of restrictive cardiomyopathy (endomyocardial fibrosis and idiopathic restrictive cardiomyopathy) in India

BACKGROUND

Restrictive heart disease is characterized by impairment of ventricular filling during diastole with preserved systolic function. The clinical and histopathological profile on endomyocardial biopsy of a cohort of patients with restrictive cardiomyopathy (RCM) is presented.

METHODOLOGY

The medical records of patients presenting with heart failure with systemic congestion, subsequently diagnosed as restrictive heart disease after evaluation including cardiac catheterisation, were studied retrospectively to determine the clinical spectrum of restrictive cardiomyopathy. The diagnosis of RCM was made, based on systemic congestion with dilated atria and near normal ventricular size and function. Only patients who had an endomyocardial biopsy were included in the study. Patients with chronic constrictive pericarditis and secondary restrictive heart disease mainly amyloidosis were excluded from the study.

RESULTS

All 52 patients had heart failure with normal or near normal left ventricular size and function. Based on right and left ventricle angiography, patients were classified into two groups. Group I with findings suggestive of EMF (n=30) and Group II no evidence of EMF on angiography i.e. 'idiopathic RCM' (IRCM) (n=22). Baseline characteristics were similar in the two groups. Echocardiography revealed typical features of endomyocardial fibrosis in Group I patients, with apical obliteration of right and left ventricular apices. Group II patients had no apex obliteration (except in four patients, who were misclassified and in whom angiography did not show apex obliteration). The Group II patients had features of IRCM in the form of normal left and right ventricular size and function with restrictive features of doppler filling along with dilated left and right atria. Angiocardiography in EMF patients showed isolated RV involvement in only two patients. In the remaining 28 patients, the obliterative changes were biventricular with RV involvement more severe than LV involvement. Angiographic findings in Group II (IRCM) patients were unremarkable with preservation of normal trabecular pattern and absence of obliterative changes. Mild atrioventricular regurgitation was present in 10/22 patients. Histopathological examination revealed that endocardial thickening was more common (77% vs. 23%) in EMF patients. The presence of myocyte hypertrophy (70-80%), myocytolysis (40-50%) and interstitial fibrosis (46-56%) were similar in both groups.

CONCLUSIONS

The majority of our patients had biventricular EMF. A significant number of patients had clinical hemodynamic features of restrictive heart disease but no evidence of EMF on angiography. These IRCM patients had similar clinical profiles to EMF but on endomyocardial biopsy the endocardial thickening was minimal and seen in few patients (5/22).

Echocardiographic profile of endomyocardial fibrosis in Tanzania, East Africa

OBJECTIVES

To demonstrate and evaluate the usefulness of two dimensional and Doppler echocardiography in the diagnosis of endomyocardial fibrosis (EMF) in countries with poor resources. Also to evaluate the clinical assessment as a predictor of echocardiographically proven EMF.

DESIGN

Descriptive hospital based study.

SETTING

Muhimbili National Hospital, Dar es Salaam, Tanzania.

SUBJECTS

39 patients (27 male and 12 female, mean age 13.5 years) attending our Cardiac Clinic were investigated to determine the extent to which specific features could be diagnosed by transthoracic echocardiography.

MAIN OUTCOME MEASURES

Identifying and characterizing echocardiographic features specific for diagnosing EMF non-invasively.

RESULTS

Only eight (21%) patients had a correct clinical diagnosis, leaving 79% of the patients at risk of being misdiagnosed and hence wrongly receiving expensive treatment. The majority of the patients (69.2%) presented with signs of elevated systemic venous pressure due to right ventricular EMF.

CONCLUSION

We have demonstrated that echocardiography remains a fundamental investigation in the least developed countries in achieving the correct diagnosis.

Increased collagen type I synthesis in patients with heart failure of hypertensive origin: relation to myocardial fibrosis

BACKGROUND

We investigated whether increased collagen type I synthesis and deposition contribute to enhancement of myocardial fibrosis and deterioration of cardiac function in patients with hypertensive heart disease (HHD).

METHODS AND RESULTS

We studied 65 hypertensives with left ventricular hypertrophy subdivided into 2 groups: 34 patients without heart failure (HF) and 31 patients with HF. Transvenous endomyocardial biopsies of the interventricular septum were performed to quantify the amount of fibrotic tissue and the extent of collagen type I deposition. The carboxy-terminal propeptide of procollagen type I (PIP), an index of collagen type I synthesis, was measured by radioimmunoassay in serum samples from the coronary sinus and the antecubital vein. Compared with normotensives, the amount of collagen tissue, the extent of collagen type I deposition, and coronary and peripheral PIP were increased (P<0.01) in the 2 groups of hypertensives. These parameters were also increased (P<0.01) in HF hypertensives compared with non-HF hypertensives. Coronary PIP was higher (P<0.01) than peripheral PIP in hypertensives but not in normotensives. The amount of collagen tissue was inversely correlated with the ejection fraction and directly correlated with both coronary and peripheral PIP in all hypertensives.

CONCLUSIONS

These findings suggest that an excess of cardiac collagen type I synthesis and deposition may be involved in the enhancement of myocardial fibrosis that accompanies the development of HF in HHD. In addition, our data show that the heart secretes PIP via the coronary sinus into the peripheral circulation in patients with HHD. Thus, PIP determined in peripheral blood can be a useful marker of myocardial fibrosis in these patients.

Multiple microembolic borderzone brain infarctions and endomyocardial fibrosis in idiopathic hypereosinophilic syndrome and in Schistosoma mansoni infestation

We report two cases of multiple distal borderzone ischaemic strokes associated with hypereosinophilia due to idiopathic hypereosinophilic syndrome in one patient and to acute Schistosoma mansoni infestation in the other. Endomyocardial fibrosis (EMF) was documented pathologically, in one case at autopsy and in the other after cardiac surgery; and by cardiac CT, with initially negative echocardiography, in one patient. These observations suggest that so called borderzone infarcts may be due to microembolisms and that, in the context of hypereosinophilia, EMF diagnosis warrants complete cardiac investigation including cardiac CT and repeat echocardiography.