Molecular detection and differentiation of enteroviruses in endomyocardial biopsies and pericardial effusions from dilated cardiomyopathy and myocarditis

Polyserositis: a diagnostic challenge

BACKGROUND

Polyserositis (PS) is the inflammation, with effusion, of different serous membranes. It has been associated with different aetiologies, but the aetiology of PS remains unknown in a high percentage of patients.

AIMS

The general objective of this retrospective study was to analyse the aetiology of PS cases seen at Son Llàtzer Hospital in an 11-year period. Other objectives were to determine the epidemiological, clinical and analytical characteristics of these patients.

METHODS

An observational, descriptive and retrospective study to analyse the aetiology of PS cases seen at Son Llàtzer Hospital. The inflammation of two or more serous membranes confirmed by an imaging test was required and at least one of the serous fluid should be an exudate.

RESULTS

A total of 92 patients was included in the study. The most common diagnosis was neoplasm (nearly one-third of cases) followed by infectious and autoimmune diseases. PS aetiology was unknown in more than one-third. Pleura and pericardium were the most common sites of serosal involvement (83%). Antinuclear antibodies' positivity in serum and increased levels of adenosine deaminase in pleural effusion were significantly associated with a final diagnosis of autoimmune disease. Increased pleural lactate dehydrogenase levels were significantly associated with a final diagnosis of neoplasm. In 9 of 14 patients with a previous cancer, PS represented a recurrence of their cancer. Cases of unknown aetiology presented most frequently as pleural and pericardial involvement, and the majority resolved. In very few patients, an infectious aetiology could be proven.

CONCLUSION

PS is a frequent clinical entity that is associated with different diseases and its diagnosis could be challenging, with a high rate of unknown aetiologies.

Enteroviruses as a possible cause of hypertension, dilated cardiomyopathy (DCM) and hypertensive heart failure (HHF) in South western Nigeria

BACKGROUND

Human enteroviruses have long been associated with various diseases of man resulting into a wide range of acute symptoms involving the cardiac and skeletal muscles, central nervous system, pancreas, skin and mucous membranes.

OBJECTIVE

To assess the role of enteroviruses in the etiology of hypertension, DCM and HHF.

METHODS

We obtained stool specimens from 70 subjects comprising 65 patients and 5 controls and isolation was carried out on RD, L20B, HEp-2C and Vero cell lines and identified by neutralization with standard antisera (RIVM). Thirty-six enteroviruses were isolated and identified to be Coxsackieviruses-B5, A9, Echoviruses 1, 6, 7, 9, 11, 12, 22, 30 and Poliovirus type 1 and 3.

RESULTS

Three most frequently occurring enterovirus serotypes which constitute 60.0% of the 30 NPEV typed and 50.0% of all the isolates were Echoviruses, Coxsackie-B5-virus and Coxsackievirus-A9. Echoviruses constituted 50.0% of all the serotypes while Coxsackieviruses-B5 and A9 accounts for the 27.8 % and 5.6% respectively. Enteroviral isolation rate was higher in age groups 51 years and above. The percentage of study subjects who had Coxsackie-B5-viruses and echoviruses was significantly (P<0.05) higher in cases of hypertension, HHF and DCM than in control subjects. Coxackie-B5-virus, Echovirus-6 and Echovirus-11 were found in both study locations.

CONCLUSION

The findings of this study showed that Enteroviruses may likely be involved in the etiology of hypertension, DCM and HHF. Further studies would therefore be necessary for the prevention and control of these diseases.

Evaluation of immunohistochemistry and in situ hybridization methods for the detection of enteroviruses using infected cell culture samples

BACKGROUND

Enterovirus infections are frequent in all age groups. In addition to acute infections, they have been connected to chronic diseases such as cardiomyopathies and type 1 diabetes. Based on this there is an increasing need for the reliable detection of enteroviruses in different kinds of tissue samples.

OBJECTIVES

The aim of this study was to set up a test panel which can detect a wide range of different enteroviruses in paraffin-embedded samples and fresh frozen samples using immunohistochemical and in situ hybridization methods.

STUDY DESIGN

A panel of nine enterovirus antibodies was optimized for the detection of different enterovirus types in both paraffin-embedded and frozen cell culture samples. In addition, an oligonucleotide probe detecting all human enteroviruses was evaluated for ISH in formalin-fixed paraffin-embedded cell culture samples.

RESULTS

Most antibodies worked well in both sample types. Some antibodies detected only one of the tested serotypes, whereas others detected several serotypes. ISH was able to detect all tested enterovirus types.

CONCLUSIONS

This test panel makes it possible to detect a wide range of different enterovirus types in both formalin-fixed paraffin-embedded and frozen samples. The same methods can also be applied for tissue sections, but may need further optimization for each tissue type.

High prevalence of chronic myocarditis in dilated cardiomyopathy referred for left ventriculoplasty: expression of tenascin C as a possible marker for inflammation

The objectives of this study were to analyze the incidence of chronic myocarditis in dilated cardiomyopathy and to evaluate the diagnostic value of tenascin C for assessing inflammatory activity in the resected myocardium. Dilated cardiomyopathy patients with chronic myocarditis have a poor clinical outcome despite recent advances in medical treatments. Therefore, a precise diagnosis of inflammatory activity is critical to ensuring appropriate therapy. Tenascin C is an extracellular matrix glycoprotein that plays an important role in tissue remodeling in various heart diseases. Myocardial samples obtained during left ventriculoplasty from 64 patients (50 +/- 13 years, 56 men and 8 women) with dilated cardiomyopathy were examined by immunostaining for tenascin C. Histologic diagnosis was based on the Dallas criteria modified by the International Society and Federation of Cardiology task force. Nine cases (14%) had active myocarditis, 21 (33%) had borderline myocarditis, and 34 (53%) had no myocarditis. Intense tenascin C expression was observed at the site of active inflammation, with abundant cell accumulation, and in organized granulation tissue during the resolving phase but not in scar tissue during the healing phase. The ratio of tenascin C-positive area to the whole myocardium in the active and borderline myocarditis groups was significantly greater than that in the noninflammatory group. These findings suggest a high prevalence of chronic myocarditis in dilated cardiomyopathy patients and that tenascin C may prove to be a useful marker for distinguishing inflammatory cardiomyopathy from other types of dilated cardiomyopathy.

Fatal parvoviral myocarditis: a case report and review of literature

Background

Histologically documented cases of parvoviral myocarditis are exceedingly rare.

Case presentation

Here, we report a 41-year old African American immunocompetent patient who died of parvoviral myocarditis after a 10 day illness characterized by fever, headaches, generalized arthralgias, and a maculopapular rash.

Autopsy revealed an infiltrate myocarditis composed primarily of T-lymphocytes and macrophages associated with extensive myocardial fibrosis. The diagnosis of parvovirus was determined by polymerase chain reaction (PCR) on both pre-mortem serum and post-mortem myocardial tissue

Methods

DNA was extracted from tissue and serum and primers were used to amplify DNAsequences of parvovirus B19 using nested polymerase chain reaction (PCR).

Conclusion

The diagnosis of parvovirus should be considered in cases of fatal myocarditis, and diagnosis can be confirmed at autopsy by molecular techniques.

Autoimmune cardiac-specific T cell responses in dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a common cause of congestive heart failure and commonly occurs in the setting of autoimmune cardio-inflammatory processes. Consistent with this notion myocardial damage and dilatory remodeling consistent with DCM occurs upon adoptive transfer of T cell subsets reactive to self-antigens abundantly expressed in cardiac tissue. In this review we discuss etiologic mechanisms by which cardio-destructive T cells are generated during T cell ontogeny, and we review accumulated work identifying myocardial-derived T cell epitopes. Additionally, we describe several possible mechanisms whereby autoimmune T cell responses are sustained during chronic DCM. Epitope spreading, intra-cardiac persistence of pathogen-derived proteinaceous determinants, and generation of long-lived memory T cells are discussed as putative processes operative in the chronic maintenance of DCM.

[MRI in chronic myocarditis]

In most cases inflammatory changes of the myocardium are asymptomatic. If inflammatory changes of the myocardium manifest with clinical symptoms, the condition is termed myocarditis. Myocarditis is regarded as a major cause for sudden death of young adults and accounts for up to 20% of the cases. In Europe viral infections represent the most important cause of myocarditis. In chronic myocarditis, viremia is often absent and myocardial fibrosis and dilated cardiomyopathy (DCM) resulting in heart failure can occur. The role of cardiac MRI in chronic myocarditis is not yet well understood. MRI is a sensitive tool detecting myocardial fibrosis on late images after application of paramagnetic contrast agents. The region of contrast accumulation is defined as "late enhancement" (LE). Data are available now suggesting that differentiating fibrosis due to myocardial infarction from inflammatory causes is facilitated using MRI late images. Fibrosis after ischemic infarction includes the subendocardial layer of the myocardium. If the subendocardial layer of the myocardium is not involved in the fibrosis, infarction is unlikely and can be reliably excluded as an important differential diagnosis in the vast majority of affected patients.

Pericarditis

Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. New diagnostic techniques have improved the sampling and analysis of pericardial fluid and allow comprehensive characterisation of cause. Despite this advance, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently self-limiting, and non-steroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. Differentiation of constrictive pericarditis from restrictive cardiomyopathy remains a clinical challenge but is facilitated by tissue doppler and colour M-mode echocardiography. Most pericardial effusions can be safely managed with an echo-guided percutaneous approach. Pericardiectomy remains the definitive treatment for constrictive pericarditis and provides symptomatic relief in most cases. In the future, the pericardial space might become a conduit for treatments directed at the pericardium and myocardium.

Enterovirus infections: a review of clinical presentation, diagnosis, and treatment

The enteroviruses, RNA viruses of the Picornaviridae family, are ubiquitous pathogens which include more than 70 different serotypes that infect people of all ages and tend to occur seasonally in the summer and fall. Clinical manifestations may vary diversely with one serotype, while multiple serotypes can present with identical symptoms and may mimic bacterial infections. Most enterovirus infections cause benign, self-limiting disease; however, they can also produce severe and sometimes fatal illnesses such as meningitis, encephalitis, myocarditis, neonatal sepsis, and polio. Severe enterovirus infections are being diagnosed and treated earlier with better prognostic outcomes due to the advances of polymerase chain reaction technology in accurately detecting virus in patient fluids as well as the recent development of new antiviral therapies.

Coxsackie B virus infection in idiopathic dilated cardiomyopathy: clinical and pharmacological implications

Idiopathic dilated cardiomyopathy (IDC) is a myocardial disease characterised by ventricular dilatation, impaired contractility, and the symptoms of congestive heart failure. Although the causes of IDC remain uncertain, much interest has been focused on the enteroviral infection in the myocardium in the pathogenesis of this disease. Enteroviral RNA has been demonstrated in the myocardium at all stages of IDC. Recent studies using sequence analysis of enteroviral polymerase chain reaction (PCR) products have shown that the viruses detected in hearts of patients with IDC are coxsackie B. In addition, active coxsackieviral RNA replication in the myocardium has been demonstrated by strand-specific detection of viral RNA. Viral antigen has also been found in hearts with IDC by immunohistochemical techniques. In tissue culture experiments and transgenic mice, it has been shown that restricted coxsackieviral RNA replication, and not infectious virus progeny, in the myocardium can impair cardiac contractile function and lead to dilated cardiomyopathy. Coxsackieviral RNA in the myocardium can be a marker of a poor clinical outcome after partial left ventriculectomy, and might influence prognosis after heart transplantation. Therefore, there is a therapeutic need to detect replicating coxsackieviral RNA in the myocardium, and a specific therapy for coxsackie B viruses is indicated in the management of patients with virus-positive IDC.

Enterovirus infections: diagnosis and treatment

Enteroviruses cause infections that present in diverse ways and affect people of all ages. Infections peak during summer and fall epidemics and cause 10 to 15 million symptomatic infections annually in the United States. The 70 enteroviral serotypes cause illness that ranges from nonspecific fevers and rashes to life-threatening myocarditis or central nervous system disease. These common infections create a significant burden on our society and healthcare system. New developments in rapid diagnosis of enterovirus infections using polymerase chain reaction (PCR) positively affect patient management and have the potential to reduce the healthcare impact of enterovirus infection. The future holds promise for effective antiviral drugs that can treat enterovirus infections and decrease their significant morbidity and mortality.

High sequence divergence in the 5' non-coding region of reference Coxsackie B and ECHO viral strains and clinical isolates revealed by restriction fragment length polymorphism analysis

We report the restriction fragment length polymorphism (RFLP) patterns of a 440-bp-long 5' non-coding region (5' NCR) amplification target of all 34 reference Coxsackie B and ECHO (enteric cytopathic human orphan) enterovirus strains and a total of 42 serotypically pre-assigned clinical isolates, in order to afford meaningful comparisons among these patterns and those of polioviruses. The RFLP patterns of reference Coxsackie B strains differed from one another and from those of polio and ECHO reference enteroviruses except from Coxsackie B1 and B2, which, although they differed from one another, had identical RFLP patterns with ECHO 17 and 13, respectively. The 28 ECHO reference strains formed a more variable viral group including strains with RFLP patterns distinct from one another and from those of polio and Coxsackie B enteroviruses, and others with RFLP pattern identities common to other ECHO viruses and Coxsackie B1 and B2 but not polioviruses. The RFLP patterns of the clinical isolates and their corresponding serotypically assigned reference Coxsackie B and ECHO strains presented the most notable variations. The observed differences between serotype and genotype-dependent assignments within the 440-bp long 5' NCR target sequence of Coxsackie B and ECHO enteroviruses were in sharp contrast to the analogous situation with polioviruses. These findings support the specificity of the described method for clinical diagnostic genotyping of polioviruses and demonstrate that the 440-bp-long target sequence follows a different evolutionary process in polio and non-polio enteroviruses that is particularly prominent between reference non-polio strains and their serotypically assigned clinical isolates.

Myocardial inflammatory cell infiltrates in cases of dilated cardiomyopathy as a determinant of outcome following partial left ventriculectomy

Partial left ventriculectomy (PLV) can be used to treat refractory congestive heart failure caused by dilated cardiomyopathy (DCM). In order to understand the relationship between the underlying myocardial injury and early clinical outcomes after PLV, histopathologic, immunohistochemical and virologic studies of the resected myocardium were performed. The posterolateral left ventricular walls from 27 patients with idiopathic DCM were examined. Cardiomyocyte diameter, degree of myocardial fibrosis, degree of cardiomyocyte degeneration, and degree of inflammatory cell infiltration were compared with mortality rates. Polymerase chain reaction was performed to detect enterovirus genome in the myocardium. Some patients had inflammatory cell infiltrates with focal accumulations of lymphocytes and macrophages, including both cytotoxic/suppressor T-cells and helper/inducer T-cells. The number of inflammatory cells (activated lymphocytes plus macrophages/mm2) was significantly greater in patients who died of cardiac insufficiency after surgery (27.8 +/- 5.7; n = 7) than in the survivors (11.1 +/- 2.5; n = 15). There was no significant difference in the degree of myocardial fibrosis, cardiomyocyte diameter or degree of cardiomyocyte degeneration between the 2 groups. Enterovirus genome was detected in the myocardium of 9 (38%) of 24 patients examined and 5 of these enterovirus-positive hearts had severe inflammatory cell infiltrates (37.9 +/- 2.5/mm2). Early survival in patients undergoing PLV for DCM is significantly affected by the degree of myocardial inflammation, so patients with more severe or ongoing inflammation may have poor clinical outcomes. Chronic myocarditis may play an important role in the etiology and pathophysiology of idiopathic DCM.

Enterovirus infections: diagnosis and treatment

Enterovirus infections are common in both children and adults and range from benign short-lived febrile illnesses to life-threatening infections. Recent developments in nucleic acid amplification techniques now allow the rapid and sensitive diagnosis of enterovirus infections, which in turn can lead to improvements in patient management that shorten hospitalizations and reduce costs. New antiviral drugs have been developed that inhibit enterovirus replication, and early clinical trials of these compounds suggest that effective therapy for enterovirus infections is now possible.

Enterovirus RNA replication in cases of dilated cardiomyopathy: light microscopic in situ hybridization and virological analyses of myocardial specimens obtained at partial left ventriculectomy

OBJECTIVE

Recently, attention has been focused on enteroviral infection of the heart in the genesis of dilated cardiomyopathy (DCM). To determine the location of enteroviral RNA in the myocardium, we performed light microscopic in situ hybridization (ISH) and virological analyses of myocardial specimens obtained at partial left ventriculectomy (PLV).

METHODS

Posterolateral walls of the left ventricle from 26 DCM patients were examined. Myocardial specimens were tested for the presence of enteroviral genomes by polymerase chain reaction (PCR). We selected two age-matched groups (10 patients each) in which enteroviruses were either present (EV-plus group) or not (EV-minus group). For both groups, we examined in situ localization of enteroviral RNA in the myocardium by ISH.

RESULTS

In PCR studies, both sense and antisense enteroviral RNA were detected in the myocardium of seven patients in the EV-plus group. The presence of this RNA indicates active viral replication in the myocardium. Five of seven patients who exhibited both sense and antisense enteroviral RNA died early after surgery. On ISH, three patients had evidence of active replication of enteroviral genomes. Viral genomes were present in myocardial lesions, especially in endocardial sites. Viral signals were found in degenerating myocardial cells, interstitial inflammatory cells, and endothelial cells of small vessels. These positive signals were not detected in the myocardium of the EV-negative group.

CONCLUSIONS

We detected both sense and antisense enteroviral RNA in various myocardial lesions. This suggests that active enteroviral replication plays a role in the development of myocardial lesions in DCM patients. Active viral replication appears to be a prognostic factor for DCM after PLV. Further study of active viral replication in myocardial lesions will provide information useful for evaluating different therapeutic strategies for DCM.

Evaluation of viral infection in the myocardium of patients with idiopathic dilated cardiomyopathy

OBJECTIVES

The aim of this study was to evaluate the viral etiology of idiopathic dilated cardiomyopathy (DCM).

BACKGROUND

The demonstration of enteroviral genome in hearts with DCM has reinforced the importance of enteroviruses in the pathogenesis of DCM. However, there is uncertainty about the character and activity of enteroviruses detected in the myocardium. Recently, the association of hepatitis C virus or adenovirus with DCM has been reported.

METHODS

Myocardial specimens from 26 patients with idiopathic DCM, which were obtained at partial left ventriculectomy (PLV), were examined virologically. Strand-specific detection of enteroviral RNA was performed to differentiate active viral replication from latent persistence. Polymerase chain reaction was used to detect genomic sequences of hepatitis C virus, adenovirus, cytomegalovirus, influenza viruses, mumps virus, herpes simplex viruses, varicella-zoster virus and Epstein-Barr virus.

RESULTS

Plus-strand enteroviral RNA was detected in 9 (35%) of the 26 patients. Minus-strand enteroviral RNA was determined in seven (78%) of these nine plus-strand RNA-positive patients. Sequence analysis revealed that the enteroviruses detected were coxsackie B viruses, such as coxsackievirus B3 and B4. However, genetic material from other viruses was not detected. Six (86%) of seven minus-strand enteroviral RNA-positive patients died of cardiac insufficiency within the first six months after PLV.

CONCLUSIONS

Coxsackie B viruses were seen in hearts with idiopathic DCM. Active viral RNA replication appeared to be present in a significant proportion of these cases. Minus-strand coxsackieviral RNA in the myocardium can be a marker for poor clinical outcome after PLV. There was no evidence of persistent infection by other viruses in hearts with DCM.

Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis

OBJECTIVE

To test the hypothesis, using endomyocardial biopsies, that unexplained cases of apparent acute myocardial infarction were caused by myocarditis.

MATERIAL

Between 1992 and 1998, 12 patients were admitted to the coronary care unit with severe chest pain, ST segment elevation, increased serum creatine kinase and MB isoenzyme, and with wall motion abnormalities on echocardiogram highly suggestive of acute myocardial infarction. These patients were further investigated by endomyocardial biopsy, as their coronary angiograms were normal. A diagnosis of myocarditis was made according to the Dallas criteria. A panel of antibodies was used for immunohistochemical characterisation of inflammatory cell infiltrate. Polymerase chain reaction (PCR) was used to detect viral genomes in seven cases.

RESULTS

Haematoxylin and eosin staining of the endomyocardial biopsy showed active myocarditis in six patients and borderline myocarditis in one. Immunohistochemistry was positive for inflammatory cell infiltrates in 11 patients, including all the seven who were positive on haematoxylin and eosin staining according to the Dallas criteria. Only one patient had no evidence of inflammation. PCR was positive in two patients, both for Epstein-Barr virus. Follow up showed complete resolution of echocardiographic abnormalities in all patients except one.

CONCLUSIONS

Myocarditis can mimic acute myocardial infarction in patients with angiographically normal coronary arteries, leading to errors of treatment. In patients with apparent myocardial infarction and a normal coronary angiogram, endomyocardial biopsy may help in the diagnosis of myocarditis. The sensitivity of endomyocardial biopsy was enhanced by using immunohistochemical and molecular biological techniques.

Molecular screening by polymerase chain reaction detects panleukopenia virus DNA in formalin-fixed hearts from cats with idiopathic cardiomyopathy and myocarditis

Viral myocarditis has been suggested as an etiology for cardiomyopathy in several mammalian species. Myocarditis and idiopathic cardiomyopathy have been reported in the domestic cat, although a viral etiology has not been demonstrated. Because of the continuing interest in the potential relationship between viral myocarditis and cardiomyopathy, we evaluated hearts from cats with spontaneous, idiopathic cardiomyopathy for viral genomic material within myocytes by polymerase chain reaction, and for the presence of myocarditis by light microscopy. Thirty-one (31) formalin-fixed hearts from domestic cats who died of idiopathic cardiomyopathy were randomly selected from pathology archives. Seventeen (17) formalin-fixed hearts from healthy cats were similarly selected as normal controls. The polymerase chain reaction (PCR) was used to evaluate myocardial tissue for the presence of viral genome from feline panleukopenia virus, herpes virus, calici virus, and corona virus. Hearts were examined using light microscopy for histologic evidence of myocarditis according to the Dallas criteria. Panleukopenia virus was identified by PCR in 10 of 31 cats with cardiomyopathy but in none of the controls. Neither cardiomyopathic or control cats tested positive by PCR for herpes virus, calici virus, and corona virus. Myocarditis was detected by histologic examination in 18 of 31 cardiomyopathic cats and in none of 17 control cats. Myocarditis and or feline panleukopenia virus genome was detected in felines with idiopathic hypertrophic, dilated, and restrictive cardiomyopathy, suggesting a possible role of viral infection and inflammation in the pathogenesis of cardiomyopathy in this species.

Myocardial inflammatory cell infiltrates in cases of dilated cardiomyopathy: light microscopic, immunohistochemical, and virological analyses of myocardium specimens obtained by partial left ventriculectomy

OBJECTIVE

Partial left ventriculectomy was introduced for the treatment of refractory dilated cardiomyopathy (DCM). To determine the presence and degree of inflammatory cell infiltrates in DCM and the correlation between the underlying myocardial injury and early clinical outcomes after the operation, we performed histopathological, immunohistochemical, and virological studies of the resected myocardium.

METHODS

Posterolateral walls of the left ventricle from 13 idiopathic DCM patients (9 males and 4 females; mean age = 53+/-14 years) were examined. Qualitative and quantitative analyses of the interstitial fibrosis and of the infiltrating inflammatory cells were conducted. For the immunohistochemistry, leukocyte surface markers and antibodies to adhesion molecules and cytokines were used. The histopathological findings were compared with the clinical results, including outcome within 1 year, and pre- and postoperative hemodynamic data. Genomic analysis of the myocardium with polymerase chain reaction was performed for enterovirus, mumps, influenza A, cytomegalovirus, and hepatitis C virus.

RESULTS

(1) The three patients who died of cardiac insufficiency after surgery had a higher count of infiltrating inflammatory cells than the eight survivors (32.1+/-10.4 vs 16.3+/-11.9 cells/mm2, p = 0.07). The severity of interstitial fibrosis (percent fibrosis) did not differ significantly between these two groups (28.3+/-15.0 vs 24.0+/-11.7%). (2) In patients who died of myocardial dysfunction, focal accumulations of lymphocytes were common, in which cytotoxic/suppressor T cells and helper/inducer T cells were observed. (3) Enterovirus genome was detected in the myocardium of two patients, both of them died after surgery.

CONCLUSIONS

Inflammatory cell infiltrates or active myocarditis appear in some cases to play an important role in the etiology and pathophysiology of clinically diagnosed DCM. There is a possibility that those patients with a more severe or ongoing inflammatory process might have poor outcomes after partial left ventriculectomy.