Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

[Severe calcifying atherosclerosis of the thoracic aorta with symptoms of aortic isthmus stenosis. Case report]

Calcifying obliterative atherosclerosis isolated within the descending thoracic aorta causing subtotal vascular occlusion was associated with symptoms such as in aortic coarctation in a 56-year-old patient. Remarkable in this unique case is the atypical and isolated manifestation of atherosclerotic disease within the thoracic aorta, as well as the tumorous extent of luminal calcification. Differential diagnostic considerations had to include calcifying tumor of the aorta, remnants after aortitis or secondary calcified aortic dissection.

Pericardioscopy and epicardial biopsy--new diagnostic tools in pericardial and perimyocardial disease

Pericardioscopy is a new diagnostic tool for macroscopic visualization of alterations in both the epicardium and pericardium. We report on 35 patients with pericardial effusion due to inflammatory perimyocardial disease. After puncture of the pericardial effusion, an 8F sheath was introduced over a guidewire under X-ray control. The pericardial pressures were measured; the fluid was removed by aspiration and exchanged with 100 ml of body-warm saline until the pericardial fluid was clear. To visualize the peri- and epicardium, for video- and photo documentation, two sorts of 8F endoscope were used, either a flexible fibreglass version or a rigid 110 degree one--both made by Storz. Cytology of the fluid and optically guided and controlled epicardial and pericardial biopsies were performed to classify the form of pericarditis. A specific diagnosis of viral pericarditis could thus be established in seven cases--by in situ hybridization for cytomegalovirus (n = 3) and by microneutralization test for enteroviruses and/or coxsackievirus B4 isolation (n = 4); of lymphocytic perimyocarditis in 16; of bacterial pericarditis in seven and antibody-mediated autoreactive pericarditis in five cases.

[Löffler endocarditis fibroplastica with simultaneous infectious endocarditis]

The clinical and immunological 8-year follow-up of a 45-year old female with hypereosinophilic syndrome and cardiac involvement of Löffler's fibroplastic endocarditis which was complicated by infective endocarditis during immunosuppressive treatment is presented. All 3 stages of the disease were documented by clinical and histologic data: stage 1 by biopsy proven eosinophilic myocarditis and arteritis, stage 2 with Berlin blue positive parietal thrombosis, and the fibrotic features of stage 3 both by fibrosis in the latest biopsies and by echocardiography. It was remarkable, however, that this classic clinical case of Löffler's endocarditis lacked a few serological markers postulated to be found regularly, e.g., a positive staining for the cationic protein and major ribonucleases. Instead, the patient demonstrated all the immunological features of autoreactive myocarditis with cytolytic, complement fixing antimyolemmal antibodies. After an initial loading dose of 120 mg prednisolone per day for 6 weeks (11/1986), the steroid dosage was reduced to 40 mg (12/1986) and diminished to 15 mg/day in 1988 to 1989. Finally, the patient was on 4 mg prednisolone per day for almost 4 years. In 1987, azathioprine was added in the dose of 150 mg/day for 6 weeks. In 3/1994 the patient developed infective endocarditis with streptococcus sanguis and presented with dyspnoea. By echocardiography a large floating structure was diagnosed on the anterior mitral leaflet and the left atrium was enlarged by severe mitral regurgitation. Infective endocarditis was successfully treated with antibiotics, but mitral regurgitation made valve replacement obligatory.

[Diagnosis of Ebstein's anomaly with transesophageal echocardiography]

We describe a 63-year old female patient presenting with increasing dyspnea on exertion. The chest X-ray was suggestive but not compelling for Ebstein's anomaly. Although Ebstein's anomaly is most often discovered first in childhood, rare cases, such as ours, are described in late adulthood, however. Obesity may be one reason why it was not possible in our patient to detect the characteristic features in transthoracic echocardiography. The diagnosis of Ebstein's anomaly could be established only by transesophageal echocardiography: There the right atrium was grossly enlarged due to the distal insertion of the septal tricuspid valve leaflet. Colour flow echocardiography clearly demonstrated severe tricuspid valve incompetence. No additional congenital or acquired cardiac disorder could be detected. Cardiac catheterization confirmed the echocardiographical findings, whereas magnetic resonance tomography did not show the abnormal insertion of the tricuspid valve leaflet. If Ebstein's anomaly is suspected and cannot be ascertained by transthoracic echocardiography, transesophageal echocardiography can be employed to definitely diagnose this fairly rare form of congenital heart disease in an adult population.

[Biventricular inflow tract compression by chronic organized hemopericardium in Caplan syndrome]

We report the case of a 59-year old patient with the rare combination of silicosis and rheumatoid arthritis, which is called Caplan's syndrome. The patient presented with right heart failure caused by a pericardial tumor compressing the right and the left ventricle. By means of several imaging techniques it was possible to elucidate the topographic relations of the tumor. Definite signs of malignant growth were not found. Despite his elevated perioperative risk we decided to operate on the patient. During the operation macroscopic and histologic evidence revealed that the tumor was not a neoplastic process but consisted of an organized hemopericardium. This demonstrates that pericarditis in rheumatoid arthritis can be hemorrhagic and can mimick a malignant pericardial tumor. The decision to operate was first supported by the findings of the applied imaging techniques, the normal endomyocardial biopsy, and the clinical course and were later confirmed in situ.

[Malignant angiosarcoma of the right atrium in pregnancy. Diagnostic and therapeutic problems]

Primary tumors of the heart, in contrast to secondary metastatic tumors show a very rare occurrence. About 25% of all primary cardiac tumors are malignant with angiosarcomas being the most frequent type of tumor. The clinical presentation include pericardial tamponade by hemorrhagic pericardial effusion, right heart failure, lung embolism and thoracal pain. Diagnostic procedures include echocardiography, magnetic resonance imaging, CT scan, angiography, pericardioscopy and finally surgical exploration. We report on a 27-year old pregnant woman (23rd week) with a malignant primary angiosarcoma of the right atrium. The patient was admitted to the hospital with progressive shortening of breath due to pericardial tamponade from pericardial effusion. A tumor of the right atrium was detected by echocardiography. Diagnostic procedures had to consider the pregnancy of the patient. Transesophageal echocardiography, magnetic resonance imaging and finally angiography of the right heart with tumor biopsy were performed. Histological examination did not show any signs of malignancy. After corticosteroids pericardial effusion disappeared. Surgical exploration of the tumor was not performed because of the pregnancy. Two weeks later the patient underwent emergency surgery because of progressive heart failure due to obstruction of the tricuspidal valve by the tumor. Thereby intrauterine death of the fetus occurred. The tumor was removed and the right atrium was reconstructed using a Dacron patch. Adjuvant chemotherapy was performed. Eight months later the tumor recurred and heart transplantation was performed. two months later pulmonary metastases were found. the patient died 20 months after onset of symptoms. This is a rare case of the very unusual coincidence of pregnancy and a primary malignant heart tumor.

[Eosinophilic endomyocarditis post partum or pregnancy-related cardiomyopathy]

We report the case of a 28-year old asthmatic female patient, who developed an acute heart failure beginning with diarrhea, fever, and dyspnea 5 weeks after delivery. After improvement of all vital functions and dismissal from hospital care unit a marked blood hypereosinophilia, left ventricular congestive heart failure, pericardium effusion and fever up to 40 degrees C followed. Endomycardial, bone marrow and skeletal muscle biopsies and the pericardial fluid showed a marked eosinophilic infiltration or polymyositis, respectively, which could be treated successfully with steroids and azathioprin. During steroid medication cytomegalovirus-associated myocarditis developed and was diagnosed by in situ hybridization. CMV hyperimmunoglobulin treatment (Cytotect, Biotest) was started (2 ml/kg bw on day 1 and 3, and 1 ml/kg on days 5, 7 and 9), which led to the eradication of the residual infiltrate and CMV-DNA in the myocardium. After discontinuation of all medication, eosinophilia and asthma recurred so that immunosuppressive treatment was continued.

Value and limitations of transesophageal echocardiography in infective endocarditis

Echocardiography has contributed considerably to the evolution in the management of patients with infective endocarditis. There is a clear hierarchy with respect to sensitivity of the different methods is superior when compared to 2-D and M-mode echocardiography in identifying both vegetations and perivalvular complications e.g. abscess formation, aneurysms, mural endocardial lesions. For patients with suspected endocarditis, in whom vegetations can not be clearly identified or in whom abscess formation is suspected with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with mono- or multiplane scans has become the standard diagnostic procedure. For the examination of prosthetic valves it is the method of choice. It has even been suggested that it is employed as routine measure in all patients with suspected infective endocarditis. TEE is a safe semi-invasive technique with an extremely low complication rate and high sensitivity. Its specificity depends largely on the patient group which is examined. In patients with indicative clinical symptoms the specificity and the predictive value of vegetations are high. When used as screening method to assess echodense formations at cardiac valves particularly in the elderly, in whom degenerative changes prevail, its specificity and positive predictive value of vegetation-like structures are much lower. The negative predictive value of a negative transesophageal echocardiogram remains high, however. Valve abscesses are detected rarely by transthoracic echocardiography. It is the domain of TEE to assess them particularly in the aortic and mitral valve area. For them the specificity and positive predictive value of TEE in the diagnosis of infective endocarditis is high again. Of further importance was the observation that patients with vegetations of > 10 mm were more likely to suffer embolic complications. It should be noted, however, that infective endocarditis remains a clinical diagnosis: neither is the demonstration of a vegetation already the equivalent of endocarditis, nor does missing vegetations completely rule out the possibility of it. But without doubt, the presence of vegetations, of abscess formation or a concomitant pericardial effusion add valuable information to clinical diagnosis of infective endocarditis, which still needs a "high index of suspicion".

[Pericardioscopy--a new window to the heart in inflammatory heart diseases]

Pericardioscopy is a new diagnostic tool to visualize macroscopically alterations of both the epicardium and pericardium. For the first time the macropathology of the epicarditis and pericarditis can be observed in vivo by the cardiologist in viral, bacterial, uremic and autoimmune cardiac processes. It enables us also to get an insight into neoplastic and metastatic processes affecting the heart and the pericardium. The prerequisite is the documentation of a larger pericardial (greater than 150 ml by the cubic model) effusion with an echocardiographically documented effusion of type C (Figure 1b), which must have at least 5 mm separation of the epicardial and pericardial layer in diastole at the anterior side of the heart when echocardiographic imaging is performed from the subxyphoidal or third intercostal space (Figure 1a). The first experience in 30 patients is reported. After puncture of the pericardial effusion a 9F sheath was introduced by use of a guide wire under echocardiographic and/or x-ray control (Figure 3). The fluid was removed by aspiration and 100 to 150 ml of body warm saline were infused in the pericardial sack. A flexible 8F fiber glass instrument (Vantec, Baxter or Storz) and a rigid 110 degrees 8F endoscope (Storz) were used for visualization of peri- and epicardium and for video documentation (Figure 2). After endoscopic inspection of the macropathology fibrinous strands (Figure 4) or increased vascular injection (Figure 5) can be observed in viral, autoimmune or idiopathic pericarditis or perimyocarditis. In the latter three forms of pericardial effusion only inflammatory cells (Figure 6) can be observed when the pericardial fluid is analyzed.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired myocyte function in vitro incubated with sera from patients with myocarditis

Sera positive for antimyolemmal antibodies (AMLAs) from patients with acute biopsy-proven myocarditis exerted a cytotoxic effect on cardiocytes stimulated in vitro. Using an edge-detecting system, contraction amplitude and contraction velocity were altered after the addition of AMLA-positive sera when compared to sera from healthy controls. Antibodies alone did not change the functional parameters. Only the presence of complement and heart-reactive antibodies mediated the detrimental effects. This suggests that a complement-mediated antibody-dependent immune mechanism is operative in human myocarditis.

Pericardioscopy--a new diagnostic tool in inflammatory diseases of the pericardium

Pericardioscopy is a new diagnostic tool to visualize macroscopically alterations in both the epicardium and pericardium. The first experience in 30 patients is reported, after pilot investigations were carried out in experimental animals. After puncture of the pericardial effusion a 9F sheath was introduced under echocardiographic and/or x-ray control. The fluid was removed by aspiration and 100-150 ml of body warm saline were infused in the pericardial sack. A flexible 8F fiberglass instrument (Vantec, Baxter or Storz) and a rigid 110 degree 8F endoscope (Storz) were used for visualization of peri- and epicardium and for video documentation. Complementary to visualization, optically-guided and controlled epicardial and pericardial biopsies were performed and analysed further. Specific diagnosis of pericardial effusion is thus greatly facilitated by the triad, pericardioscopy, cytology and epicardial as well as pericardial biopsy.

Are antisarcolemmal (ASAs) and antimyolemmal antibodies (AMLAs) "natural" antibodies?

Antisarcolemmal (ASAs) and in particular antimyolemmal antibodies (AMLAs) are a serologic hallmark of inflammatory heart muscle disease and its sequelae. Since they may also occur to a much lesser incidence with increasing age, it was examined whether they also possess properties of "natural antibodies". As natural antibodies, AMLAs and ASAs have specificity for conserved structures on the membrane. They possess cross-reactivity and increase with age. In contrast to natural antibodies, however, they occur most frequently after viral stimulation, and are more often of the IgG- and IgA- than of the IgM-isotype and fix complement in the acute stage of the disease. They also exhibit cytolytic and cytotoxic properties when incubated in vitro with isolated heart muscle cells. In addition, antigenic mimicry has been demonstrated to be operative, since they are cross-reactive to viral proteins.

Immunological features in a case of hypereosinophilic syndrome and myocarditis

The clinical and immunological follow-up of a 38-year-old female patient with hypereosinophilic syndrome and classical cardiac involvement, but without demonstrable degranulation of eosinophils and lacking binding of a specific antibody for activated eosinophils, is presented. Instead, the patient demonstrated all the immunological features of autoreactive myocarditis: cytolytic, complement-fixing antimyolemmal antibodies and increased concentrations of circulating immune complexes were present over 3 years.