Role of cardiac biopsy in the diagnosis and management of cardiac disease

Development of a Novel Wasp-Inspired Friction-Based Tissue Transportation Device

Currently existing tubular transportation systems for the extraction of large tissue masses during Minimal Invasive Surgery (MIS) are subjected to a large amount of operating limitations. In this study, a novel transportation mechanism (patented) was developed inspired by the egg-laying structure of wasps. The developed mechanism consists of an outer tube within which six reciprocating semi-cylindrical blades are present and tissue is transported using a friction differential between the blades. Two motion sequences were developed: (1) 1–5 motion sequence, in which one blade moves forward, while the remaining five blades move backward and (2) 2–4 motion sequence, in which four blades move backward while two blades move forward. A proof-of-principle experiment was performed to investigate the effects of tissue elasticity, tissue heterogeneity, and the motion sequence on the transportation rate [mg/s], transportation efficiency [%], and transportation reliability [%]. The mean transportation rate and reliability was highest for the 9 wt% gelatine phantoms at 4.21 ± 0.74 mg/s and the 1–5 sequence at 100%, respectively. The prototype has shown that the friction-based transportation principle has the potential of becoming a viable and reliable alternative to aspiration as a transportation method within MIS.

Radical Pericardiectomy for Chronic Constrictive Pericarditis

A retrospective analysis was undertaken in 79 patients who underwent pericardiectomy for chronic constrictive pericarditis from January 1985 to February 1999. Most operations (77) were carried out with cardiopulmonary bypass, with subtotal pericardiectomy in 75 patients, and concomitant operations in 25. Postoperative complications occurred in 8 patients: cerebrovascular accident in 2, renal insufficiency in 5, bleeding in 2, low output syndrome in 4, and respiratory insufficiency in 2. The operative mortality was 5%; causes of death were cardiac-related in all cases. Actuarial survival at 1, 5, and 10 years was 89.9% ± 3.4%, 74.9% ± 5.7%, and 55.4% ± 13.5%, respectively. Regression analysis was performed using 53 clinical variables. Female gender, renal insufficiency, concomitant coronary artery bypass grafting, and preoperative right ventricular end-diastolic pressure > 20 mm Hg were found to be predictors of poor survival. At follow-up, improved functional status was noted in 88% of patients. Subtotal pericardiectomy can be performed on cardiopulmonary bypass with low mortality and good long-term survival.

Tricuspid annular motion velocity as a differentiation index of hypertrophic cardiomyopathy from hypertensive heart disease

BACKGROUND

Hypertensive heart disease (HHD) and hypertrophic cardiomyopathy (HCM) are the most frequently encountered entities presenting left ventricular hypertrophy in routine echocardiographic examination, and their differentiation is sometimes difficult. Abnormalities in right ventricular (RV) myocardium have been reported frequently in patients with HCM more than in those with HHD. We therefore hypothesized that tricuspid annular motion (TAM) velocity determined by pulsed tissue Doppler echocardiography can be used to detect RV dysfunction in HCM and discriminate these etiologies.

METHODS

TAM velocities were compared among clinically stable patients with 60 HCM and 60 HHD patients as well as 60 age-matched healthy controls. Peak systolic, early diastolic (TAM-e'), and atrial systolic velocities were measured. RV myocardial performance index was measured by tissue Doppler method. To more accurately differentiate HCM from HHD, electrocardiographic findings and brain natriuretic peptide levels, which can both be examined simply and noninvasively, were investigated in addition to echocardiography.

RESULTS

RV wall thickness of the HCM group was greater than the HHD group (p=0.092), while there was no significant difference in RV myocardial performance index between the HCM and HHD groups (p=0.606). TAM-e' was significantly lower in the HCM group than in HHD and control groups (p=0.001). To differentiate HCM from HHD, TAM-e' was a powerful predictor as per multivariate logistic regression analysis (hazard ratio, 0.665; p<0.001) of parameters other than those of left ventricular parameters, and the area under the receiver operating characteristic curve (AUC) was 0.686 and the best cut-off value was ≤8.0cm/s (62% sensitivity, 65% specificity). Multivariate logistic analysis revealed that electrocardiographic ST-T changes were the next most effective marker for differentiating HCM after TAM-e'. When TAM-e' and ST-T changes were combined, the AUC increased to 0.748.

CONCLUSIONS

TAM-e' is a potentially useful index to differentiate HCM from HHD.

Severe postpartum sepsis with prolonged myocardial dysfunction: a case report

INTRODUCTION

Severe sepsis during pregnancy or in the postpartum period is a rare clinical event. In non obstetric surviving patients, the cardiovascular changes seen in sepsis and septic shock are fully reversible five to ten days after their onset. We report a case of septic myocardial dysfunction lasting longer than ten days. To the best of our knowledge, this is the first report of prolonged septic myocardial dysfunction in a parturient.

CASE PRESENTATION

A 24 year old Hispanic woman with no previous medical history developed pyelonephritis and severe sepsis with prolonged myocardial dysfunction after a normal spontaneous vaginal delivery.

CONCLUSIONS

Septic myocardial dysfunction may be prolonged in parturients requiring longer term follow up and pharmacologic treatment.

Value of radionuclide studies in cardiac transplantation

Effective noninvasive evaluation of acute and chronic allograft rejection remains an important challenge in patients with cardiac transplantation. Radionuclide studies have demonstrated utility because of their ease of use, giving relevant information about the pathophysiology of the transplanted heart, along with valuable diagnostic and prognostic indicators. This article focuses on reviewing the pathophysiological changes of the transplanted heart and implications for radionuclide studies.

Myocardial ultrasound tissue characterization in patients with hypertrophic cardiomyopathy: noninvasive evidence of electrical and textural substrate for ventricular arrhythmias

BACKGROUND

Although in patients with hypertrophic cardiomyopathy (HCM) pathologic studies seem to suggest a correlation between morphologic findings and arrhythmias, it has never been confirmed in the clinical setting.

OBJECTIVE

We sought to noninvasively assess the electrical and textural properties of the myocardium and to define their potential relationship in patients with HCM.

METHODS

We studied 48 patients: 22 with HCM (mean age: 22 +/- 5.1 years) and 26 age- and body surface area-matched healthy patients. They underwent a standard echocardiographic examination to assess left ventricular size and thickness. In addition, by integrated backscatter analysis, we assessed textural properties of left ventricular myocardium with calibrated averaged intensity (IB) and to assess functional properties of the myocardium with cyclic variation, both at the interventricular septum (IVS) and posterior wall. Finally, we studied ventricular late potentials (VLPs) by signal-averaged electrocardiography and performed a 24-hour electrocardiography Holter monitoring to respectively define electrical instability and ventricular arrhythmias.

RESULTS

Compared with control patients, patients with HCM had, both at IVS and posterior wall, increased IB (-28.8 +/- 10 vs -35 +/- 4 dB [P =.007] and -29 +/- 8 vs -33 +/- 5 dB [P <.035], respectively) and decreased cyclic variation (6.8 +/- 2.7 vs 10.3 +/- 2.3 dB [P <.001] and 8.2 +/- 2.9 vs 11.4 +/- 2.1 dB [P <.001], respectively). In all, 5 patients with HCM had positivity of VLPs, and 4 of them showed nonsustained ventricular tachycardia (nsVT) on the Holter monitoring. Compared with patients who had HCM without VLPs and nsVT, patients with positivity of VLPs and nsVT showed higher IB both at IVS (-15.8 +/- 8.4 vs -32.6 +/- 5.9 dB [P <.001] and -16.6 +/- 9.5 vs -31.5 +/- 7.5 dB [P =.002], respectively) and at posterior wall (-19.08 +/- 8.42 vs -32.5 +/- 4.2 dB [P <.001] and -22.4 +/- 4.6 vs -31 +/- 7.5 [P =.04], respectively). A multivariate analysis showed IB at IVS (P =.042; odds ratio = 1.19) and positivity of VLPs (P =.026; odds ratio = 3.67) as independent predictors of nsVT.

CONCLUSION

Patients with HCM showed abnormal morphologic and electrical properties of the myocardium. The correlation between VLPs and IB at IVS and their relationship with nsVT suggests a link between textural and electrical nonhomogeneity of myocardial fibers, a potential substrate of nsVT in patients with HCM.

Biopsy-proven cardiomyopathy in heterozygous Fabry's disease

A 23-year-old woman with heterozygous Fabry's disease who had acroparesthesia was admitted to hospital for precise examination of the disease before childbearing. She had no cardiac-related symptoms and no abnormality on physical examination. The alpha-galactosidase A activity in her leukocytes was present, but lower than normal. However, the endomyocardial biopsy showed specific changes for Fabry's disease. As Fabry's disease is a rare X-linked recessive inborn error of glycosphingolipid metabolism, heterozygous females are usually asymptomatic, but rarely can be affected as severely as hemizygous males. This is an isolated case of heterozygous Fabry's disease in a female in whom cardiac involvement was detected by endomyocardial biopsy, although she had no cardiac abnormality on physiological examinations. In conclusion, endomyocardial biopsy is useful for evaluation of the cardiac involvement of Fabry's disease even in an asymptomatic case.

Discordance between pre and post cardiac transplant diagnosis: implications for pre- and postoperative decision making

A correct clinical diagnosis in end-stage patients undergoing cardiac transplantation may have important prognostic and therapeutic implications. A retrospective clinico-pathologic study was carried out in 257 patients who had undergone cardiac transplantation at the University of Padua. A discrepancy between clinical and pathological diagnosis was found in 20 cases (8%). Among 126 patients with the clinical diagnosis of dilated cardiomyopathy, seven were found eventually to have ischemic heart disease (IHD), five myocarditis, one arrhythmogenic right ventricular cardiomyopathy (ARVC), and one non-compacted myocardium. Among the 87 patients with clinical diagnosis of IHD, three turned out to be dilated cardiomyopathy and one granulomatous myocarditis. Among the 10 patients with the clinical diagnosis of hypertrophic-restrictive cardiomyopathy, one had ARVC and one had cardiac fibroma. Altogether, only 24.5% underwent endomyocardial biopsy (EMB) and 75% coronary angiography before transplantation. Missed diagnosis of myocarditis occurred in patients in whom EMB was not carried out. EMB and coronary angiography might be indicated routinely in patients with apparent dilated cardiomyopathy, before proceeding to cardiectomy.

Dermatopathologic findings in 20 cases of systemic amyloidosis

The clinical findings of systemic amyloidosis are often variable and nonspecific. The early recognition of this disorder relies upon clinical suspicion, and definite diagnosis requires the confirmation of amyloid deposits in tissue. We reviewed 31 skin biopsy specimens from 20 patients, including 17 with amyloid light chain (AL) protein amyloidosis and 3 with serum amyloid A (AA) protein amyloidosis. Histologically, amyloid can be present in the papillary dermis, reticular dermis, subcutis, around the appendages, and in or around blood vessels. In our series, all 20 patients had at least one positive skin biopsy. Amyloid was found in 30 of 31 specimens (97%), a higher rate than in most series. Skin biopsy is a simple, safe procedure with high yield and may be used to obtain a firm diagnosis of systemic amyloidosis.

Elevations of Cardiac Troponin I Associated With Myocarditis

Background Endomyocardial biopsy is currently the standard method used to diagnose myocarditis. However, it is invasive and has a low diagnostic yield. Because the histological diagnosis of myocarditis requires the presence of myocyte injury, we sought to determine whether measurement of cardiac troponin I (cTnI), which is a serum marker with high sensitivity and specificity for cardiac myocyte injury, could aid in the diagnosis of myocarditis.

Methods and Results To validate this approach, cTnI values were first measured in mice with autoimmune myocarditis. cTnI values were elevated in 24 of 26 mice with myocarditis but were not elevated in any of the control animals ( P <.001). Next, cTnI values were measured in the sera from 88 patients referred to the Myocarditis Treatment Trial and were compared with creatine kinase–MB (CK-MB) values measured in the same patients. cTnI values were elevated in 18 (34%) of 53 patients with myocarditis and in only 4 (11%) of 35 patients without myocarditis ( P =.01). In contrast, CK-MB values were elevated in only 3 (5.7%) of 53 patients with myocarditis and 0 of 35 patients without myocarditis ( P =.27). Thus, elevations of cTnI occurred more frequently than did elevations of CK-MB in patients with biopsy-proven myocarditis ( P =.001). Importantly, elevations of cTnI in patients with myocarditis were significantly correlated with ≤1 month duration of heart failure symptoms ( P =.02), suggesting that the majority of myocyte necrosis occurs early, and thus the window for diagnosis and treatment may be relatively brief.

Conclusions cTnI was superior to CK-MB for detection of myocyte injury in myocarditis, and cTnI elevations were substantially more common in the first month after the onset of heart failure symptoms.

A new method for isolation of cardiac myocytes by percutaneous endomyocardial biopsy

The objective of this study was to demonstrate the feasibility of isolating viable canine cardiac myocytes from percutaneous right ventricular endomyocardial biopsy specimens. Although histologic data can be obtained from percutaneous endomyocardial biopsies, this approach has not been used as a source of viable cells for evaluating pathological conditions. Study of isolated viable myocytes may provide insight into the electrical, biochemical, and physiologic functions of the heart. Using a standard 8F sheath, a 5F bioptome was introduced via the right femoral vein and advanced to the right ventricle, where 85 biopsies were obtained from 8 mongrel dogs. An average of six biopsy specimens were pooled for processing to provide adequate tissue substrate. This resulted in 14 groups of specimens which were then processed to isolate individual myocytes. Viable myocytes were striated, rod-shaped, and excluded trypan blue dye. Nonviable myocytes were rounded, had no cross-striations, and did stain with trypan blue. Partially-injured myocytes contracted spontaneously and had a region of loss of cross-striations. The average number of viable cells recovered per group of pooled specimens was 1.8 x 10(4) (1.8 x 10(3) cells/mg of tissue). The greatest yield of viable myocytes recovered was 8.0 x 10(4), which represented a viability of 90% by trypan blue dye exclusion and morphological criteria. Percutaneous right ventricular endomyocardial biopsy is a novel method for obtaining viable cardiac myocytes. Its feasibility and utility in humans warrant further investigation.

Cytokine gene expression in human cardiac allograft recipients

The long-term success of heart transplantation for end-stage heart disease has been hindered by the problems associated with acute and chronic graft rejection, opportunistic infections and potentially fatal complications of intensive immunosuppression. A more complete understanding of the biology of transplant rejection should provide the basis for the development of improved methods for controlling and monitoring rejection. Cytokines, the soluble factors which regulate the immune response, are central to the rejection process. The objective of this study was to analyse cytokine mRNA transcripts in 99 biopsy samples and 89 blood samples from 65 and 35 Stanford Medical Center cardiac transplant recipients, respectively, gathered between January 1990 and January 1992. Following RNA extraction and conversion to cDNA, samples were amplified with cytokine-specific primers for interleukins (IL) 1 to 8, TNF-beta (tumour necrosis factor-beta) and IFN-gamma (interferon-gamma) and were analysed by gel electrophoresis and Southern blot hybridization. Our results demonstrate that despite chronic immunosuppressive therapy, the peripheral blood of transplant recipients expressed a higher combined percentage of different cytokine transcripts than did peripheral blood obtained from normal volunteers. In transplant patients, detection of cytokine transcripts for IL-1 alpha, IL-1 beta and IL-2 increased with time after transplantation. Intragraft IL-7 gene expression was significantly increased in biopsies diagnosed with mild (grade 1) rejection when compared to those with no evidence of rejection or with moderate to severe rejection. Implications of these results in light of possible mechanisms of rejection and of new approaches to immunotherapy are discussed.

Tricuspid flail leaflets after orthotopic heart transplant: a new complication of endomyocardial biopsy

A case of tricuspid flail leaflets in a patient with orthotopic heart transplant is reported. The use of echocardiography to document the complication and its relationship to endomyocardial biopsy is presented.

Endomyocardial biopsy in infants and children with cardiomyopathy

We reviewed our experience of endomyocardial biopsy performed on 21 symptomatic infants and children with cardiomyopathy. Clinical congestive cardiomyopathy was noted in 18 patients, 2 had hypertrophic cardiomyopathy, and 1 a restrictive cardiomyopathy. The biopsy findings led to a diagnosis of hemochromatosis in one patient, Adriamycin cardiomyopathy in another, and lymphocytic myocarditis in a third. Five patients had features of endocardial fibroelastosis, one endomyocardial fibrosis, and a further one, a mitochrondrial abnormality. In 11 patients normal or nonspecific features were seen. There were 2 myocardial perforations, both patients being successfully resuscitated. Endomyocardial biopsy, although occasionally hazardous, may sometimes provide valuable information which may lead to a diagnosis, facilitate treatment, and be of prognostic value. Despite the low positive yield, it may still be indicated in selected patients, in view of the seriousness and often poor prognosis of this disorder: 5 of our study group subsequently died.

The incidence of myocarditis in endomyocardial biopsy samples from patients with congestive heart failure

We present the combined experience of three Yugoslavian cardiovascular centers in the application of endomyocardial biopsy for the diagnosis of myocarditis in patients who present clinically with congestive heart failure. The study group comprised 107 patients (mean age, 40.8 years; range, 19 to 61 years). On the basis of patient history and diagnostic tests, the following clinical diagnoses were established: dilated cardiomyopathy (85), myocarditis (16), and alcohol-induced heart disease (6). EMB samples were taken from the left ventricle (95) or both ventricles (12) by use of a King's College bioptome, with a mean of 3.2 samples per patient. Histologic evidence of myocarditis was noted in 10 of 85 patients (12%) with a clinical diagnosis of dilated cardiomyopathy, in 2 of 6 patients (33%) with alcohol-induced heart disease, and in 12 of 16 patients (75%) with a clinical diagnosis of myocarditis. There was confirmation of the clinically suspected diagnosis in 63% of cases, a change of diagnosis based on histology in 15% of cases, and nonspecific findings in 22%. However, useful information was obtained in 78% of the cases, and there was a 22% incidence of histologically proven myocarditis for the entire group. Our results indicate that endomyocardial biopsy is beneficial in determining the true incidence of myocarditis in patients with a clinical presentation of dilated cardiomyopathy.

Histological changes in cardiac hemochromatosis improved by an iron-chelating agent. A biopsy case

Cardiac dysfunction and ECG abnormalities were demonstrated in a 51-year-old woman suffering from secondary hemochromatosis in sideroblastic anemia. Hemosiderin deposition in vacuolized and disarrayed myocytes was disclosed by microscopic examination of the first biopsy specimen of endomyocardial tissue. Three months after administration of deferoxamine mesylate, an iron-chelating agent, the clinical findings were improved. The second endomyocardial biopsy revealed marked depletion of hemosiderin deposition in the myocytes, and improvement of myocyte vacuolization and disarray. Ultrastructurally, the highly electron-dense granules in the myocytes were also decreased in number and density. X-ray microanalysis revealed a prominent peak of Fe in the granules. In a liver specimen obtained by needle biopsy 5 months after the second endomyocardial biopsy, marked hemosiderin deposition still remained.

Safety and utility of endomyocardial biopsy in infants, children and adolescents: a review of 66 procedures in 53 patients

The benefits and risks of endomyocardial biopsy in infants, children and adolescents were determined by reviewing the indications for and complications and results of 66 procedures in 53 patients aged 2 months to 20 years. One patient had a pneumothorax, and three had a right ventricular perforation. Ventricular tachycardia developed in four patients; it was treated with lidocaine in three and was self-limited in one. The procedure was unsuccessful in two patients. Among 25 patients with a prebiopsy diagnosis of idiopathic dilated cardiomyopathy, microscopic features were consistent with cardiomyopathy in 24 (96%) and were normal in 1. Of nine patients with clinically suspected myocarditis, only two (22%) had microscopic evidence of inflammation, and seven had chronic nonspecific features suggestive of dilated cardiomyopathy. Of eight patients with unexplained arrhythmias, six (75%) had microscopic findings compatible with dilated cardiomyopathy and two had myocarditis. Biopsy tissue samples from seven patients with nondilated forms of cardiomyopathy (four hypertrophic, three restrictive) were consistent with the clinical diagnosis in six and were inadequate in one. Cardiac biopsies were also performed in four patients with other disorders. Among the 51 patients with adequate biopsy specimens, microscopic features were considered diagnostic in 5, confirmatory in 44 and not helpful in 2 with normal tissue. The results indicate that endomyocardial biopsy is safe in infants, children and adolescents. It is useful for the evaluation of cardiomyopathy and specific secondary forms of myocardial disease. There seems to be little correlation, however, between clinical and tissue diagnoses of myocarditis.

Clinical and experimental aspects of viral myocarditis

Picornaviruses are frequently implicated as the etiological agents of acute myocarditis. This association is based historically on serological evidence of rising antibody titers to specific pathogens and more recently on identification of viral genomic material in endocardial biopsy specimens through in situ hybridization. Only rarely is infectious virus isolated from either the patient or the heart during periods of maximum myocardial inflammation and injury. Thus, despite a probable viral etiology, much interest centers on the role of the immune system in cardiac damage and the likelihood that the infection triggers an autoimmune response to heart-specific antigens. Heart-reactive antibodies and T cells are found in most myocarditis patients, and immunosuppressive therapy has proven beneficial in many, though not all, cases. Furthermore, murine models of coxsackievirus group B type 3-induced myocarditis also demonstrate that virus infection initiates autoimmunity and that these autoimmune effectors are predominately responsible for tissue injury. How virus-host interactions overcome presumed self-tolerance to heart antigens is discussed, and evidence supporting various theories of virus-initiated autoimmunity and disease pathogenesis are delineated.

Myocardial iron grading by endomyocardial biopsy. A clinico-pathologic study on iron overloaded patients

Endomyocardial biopsy was performed in 13 patients with primary or secondary iron overload. Prussian blue staining showed visible iron in the biopsy fragments of 8 out of 13 patients. Because of the inhomogeneity of iron deposition in the biopsy fragments, a semi-quantitative myocardial iron grading system was used in which the percentage of Perls' positive cells on 4 to 6 biopsy fragments was averaged from each case. The presence of stainable iron in the myofibrils was not predictable from serum iron, transferrin saturation, serum ferritin or liver iron grading, nor from evidence of endocrine dysfunction. In patients with Perls' positive material in the myocardium, there was a significant correlation between the endomyocardial iron grade and serum iron and transferrin saturation. These results suggest that other factors besides the body iron load determine cardiac iron deposition. The fact that myocardial siderosis was documented only in patients with hepatic cirrhosis, irrespective of the hepatic iron load, suggests that severe liver damage may be a prerequisite for the accumulation of iron in the heart.

Coronary artery fistula in the heart transplant patient. A potential complication of endomyocardial biopsy

All follow-up annual cardiac catheterizations performed on recipients of orthotopic heart transplant were reviewed, and 14 patients with coronary artery fistula were identified. The prevalence (8.0%, 14 of 176 patients) was strikingly higher than that for patients without transplant (0.2%) who underwent routine cardiac catheterization. These 14 patients had 21 coronary artery fistulas: single in nine and multiple in five patients. Fifty-two percent arose from the right, 43% from the left anterior descending, and 5% from the circumflex coronary artery. All drained into the right ventricle. Four patients underwent oximetric evaluation, and left-to-right shunting was not detectable. No patient had symptoms attributable to the fistula. Hemodynamic measurements were similar to those of a control group of 28 age- and sex-matched recipients of heart transplant without coronary artery fistula; however, the cardiac index (p = 0.02) and pulmonary artery oxygen saturation (p = 0.03) were significantly higher, and the arteriovenous oxygen difference (p = 0.01) was significantly lower in the group with coronary artery fistula. The histologic features of rejection, large arterioles, or epicardial fat on any biopsy specimen predating coronary artery fistula diagnosis were not associated with the development of the fistula when the two groups were compared. Nine patients (11 coronary artery fistulas) had follow-up studies performed, and three fistulas were larger, three were unchanged, two were smaller, and three had resolved. No complications of coronary artery fistula developed during a mean follow-up of 28 months (range, 12-42 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of endomyocardial biopsy in infants, children and adolescents with dilated or hypertrophic cardiomyopathy and myocarditis

Endomyocardial biopsy was performed in 20 symptomatic pediatric patients with the following clinical diagnoses: dilated cardiomyopathy in 16, hypertrophic cardiomyopathy in 2 and myocarditis in 2. Transfemoral biopsy was performed without complications in patients aged 2 months to 16 years; 6 were less than 1 year old. An average of five right ventricular specimens were obtained for histologic and ultrastructure study from each patient. In 16 patients with the clinical diagnosis of dilated cardiomyopathy, biopsy findings were compatible with the diagnosis in 8, but changed the diagnosis as follows in the other 8: myocarditis, 4; hypertrophic cardiomyopathy, 2 and carnitine deficiency syndromes, 2. In two patients with the clinical diagnosis of hypertrophic cardiomyopathy, biopsy findings confirmed the diagnosis in one and were normal in the other who had an encapsulated cardiac fibroma at operation. In two patients with the clinical diagnosis of myocarditis, biopsy findings confirmed the diagnosis in one and suggested dilated cardiomyopathy in the other. In the entire series, 25% had biopsy evidence of inflammatory disease. Biopsy findings were confirmed at subsequent autopsy in five cases.

Congestive heart failure

Congestive heart failure (CHF) is not a single entity but a symptom complex that may represent the consequence of mechanical abnormalities, myocardial abnormalities, and/or disturbances of cardiac rhythm. In turn, it affects virtually every organ system in the body. This review focuses on CHF due to systolic dysfunction of the left ventricle, which comprises the majority of cases of this condition. Recent data suggest that CHF may be the most frequent primary diagnosis in patients on medical services in nonmilitary hospitals in this country: it affects approximately 2% of the United States population, or some 4 million people. The mortality rate for CHF is also worse than for many forms of cancer; thus, new therapeutic alternatives are imperative. In order to devise new therapeutic strategies, a detailed understanding of the pathophysiology of this condition is required. The relative advantages and disadvantages of various pharmacologic and nonpharmacologic approaches are considered in detail. Certain medications, such as the angiotensin converting enzyme (ACE) inhibitors, have been shown to improve survival, and heart transplantation is clearly life-saving for those who are eligible for this therapy. However, the real challenge is to devise strategies to prevent the occurrence of heart failure, or interrupt its progress at a very early stage.

Dilated cardiomyopathy: diagnostic accuracy of endomyocardial biopsy

A histopathological index of contractility failure, which was reported to be accurate for the diagnosis of idiopathic dilated or congestive cardiomyopathy in Japan, was used to assess endomyocardial biopsy specimens from 41 Dutch patients with suspected dilated cardiomyopathy. The calculated index had a sensitivity of 62.5% and a specificity of 68% for idiopathic dilated or congestive cardiomyopathy. These disappointing results indicate that the histopathological index of contractility failure does not reliably distinguish between idiopathic dilated cardiomyopathy and other diseases that cause congestive heart failure.

Histopathologic and ultrastructural observations of acute and convalescent myocarditis: a serial endomyocardial biopsy study

Serial endomyocardial biopsy findings were analyzed in ten cases with acute myocarditis of possible viral origin. The histopathologic findings were analyzed at the acute (0-10 days after the onset), subacute (11-21 days), and convalescent stages (22-167 days). The incidence and severity of various cardiac myocyte and interstitial changes were compared at each stage of the disease. The time-course changes of the histopathologic findings in acute myocarditis were as follows. At the acute stage, we observed: interstitial cell infiltration composed of fibroblasts, macrophages, and lymphocytes, fragmentation of the muscle bundles, myocytolytic changes, swelling and scarcity of the cytoplasm and swelling of nuclei, variation in size of the myocytes, disarrangement of the muscle bundles, interstitial edema, increased glycogen deposition in the myocytes, abnormal branching of the myocytes, and interstitial fibrosis. At the convalescent stage, most of the above findings could still be seen except for myocytolytic changes, swelling of myocytes, and interstitial edema. At the subacute and convalescent stages, an increase in abnormal branching and in double nuclei in the myocytes and nuclear degeneration became observable. A further control study comparing the changes at the convalescent stage of myocarditis and the myocardial changes in cases with chronic right ventricular overload in 58 cases revealed that in the former fragmentation of the muscle bundles, abnormal branching, size variation, glycogen deposition, and large mononuclear cell infiltrations were significantly more frequent. Ultrastructural observation of the myocytes revealed that they have a great potentiality for regeneration; myocytes showing severe myocytolytic changes may recover to regain an architecture of almost normal appearance.