The Restrictive Cardiomyopathies

Current concepts in diagnosis and perioperative management of carcinoid heart disease

Carcinoid tumors are neuroendocrine tumors with a very unpredictable clinical behavior. In the setting of hepatic metastases, the tumor's release of bioactive substances into the systemic circulation results in carcinoid syndrome: a constellation of symptoms among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most prominent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe fibrotic reaction which frequently involves the right-sided valves and may extend towards the subvalvular apparatus leading to valve thickening and retraction. Left-sided involvement is rare and mostly observed in the presence of an interatrial shunt, endobronchial tumor localization, and high tumor activity. Echocardiographic techniques often reveal noncoaptation of the valves, which are fixed in a semiopen position. In patients with advanced lesions and severe valvular dysfunction, surgery is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend towards improved surgical outcomes has triggered a more liberal referral for valve replacement. Carcinoid heart disease poses two distinct challenges for the anesthesiologist: carcinoid crisis and low cardiac output syndrome secondary to right ventricular failure. Carcinoid crisis, characterized by flushing, hypotension, and bronchospasm, may be precipitated by catecholamines and histamine releasing drugs used routinely in patients undergoing valve surgery. Although a broader utilization of octreotide have significantly simplified the anesthetic and perioperative management of these patients, a very balanced anesthetic technique is required to identify and manage low cardiac output syndrome.

Constrictive pericarditis and restrictive cardiomyopathy in the modern era

The differentiation between constrictive pericarditis and restrictive cardiomyopathy can be clinically challenging. Pericardial constriction results from scarring and consequent loss of pericardial elasticity leading to impaired ventricular filling. Restrictive cardiomyopathy is characterized by a nondilated rigid ventricle, severe diastolic dysfunction and restrictive filling producing hemodynamic changes, similar to those in constrictive pericarditis. While constrictive pericarditis is usually curable by surgical treatment, restrictive cardiomyopathy requires medical therapy and in appropriate patients, the definitive treatment is cardiac transplantation. Sufficient differences exist between the two conditions to allow noninvasive differentiation, but no single diagnostic tool can be relied upon to make this distinction. Newer echocardiographic techniques such as speckle-track imaging, velocity vector imaging, as well as cardiac computed tomography and cardiac MRI can help differentiate constriction from restriction with high sensitivity and specificity. Outcomes are better with early diagnosis of constriction in particular and early surgical resection.

From an isolated right ventricular thrombus to the diagnosis of the hypereosinophilic syndrome

This case concerns a 58-year-old male who presented with abdominal pain, anorexia, nausea, and exertional dyspnea of one month's duration. On further evaluation peripheral eosinophilia was conspicuous and eosinophilic infiltration was found in the gastrointestinal system and bone marrow. Echocardiography showed an isolated right ventricular thrombus with tricuspid valve involvement. Cardiac magnetic resonance imaging helped to confirm the diagnosis of cardiac involvement in hypereosinophilic syndrome without requiring a cardiac biopsy.

Large apical thrombus in a patient with persistent heart failure and hypereosinophilia: Löffler endocarditis

Idiopathic hypereosinophilic syndrome is an uncommon leukoproliferative systemic disorder characterized by the overproduction of eosinophils and poor prognosis. A major source of morbidity and mortality of this syndrome is the associated cardiac involvement represented by endocardial thickening and mural thrombi. We report a 64-year-old woman with persistent symptoms of heart failure despite standard medical therapy. Echocardiography revealed reduced left ventricular filling due to a large apical mass; an abnormal diastolic filling pattern was also noticed. Complete blood count revealed remarkable hypereosinophilia. Cardiac magnetic resonance imaging demonstrated an apical thrombus and intense linear enhancement of the endocardium, which were compatible with Löffler endocarditis. Medical therapy, including corticosteroids and anticoagulation, was initiated promptly. The symptoms improved as the peripheral hypereosinophilia resolved in 15 days. The patient was asymptomatic at the 1-year follow-up visit with complete regression of the apical thrombus and no evidence of restrictive cardiomyopathy. We report this case to draw attention to this particularly rare condition with poor prognosis since quick and accurate diagnosis and prompt initiation of therapy may improve symptoms and survival.

Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist

BACKGROUND

The management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs.

METHODS

We analysed a series of 11 patients [six males, median (range) age 60 (42-73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007.

RESULTS

All patients received octreotide intraoperatively [650 (300-1050) microg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300-850) vs 750 (650-1050) mug]. Similarly, the use of greater doses of aprotinin (> 5 KIU) was associated with greater requirements for octreotide [475 (300-700) vs 750 (320-1050) microg] and higher glucose levels (> or =8.5 mmol litre(-1)). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed.

CONCLUSIONS

Carcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.

Extracardiac medical and neuromuscular implications in restrictive cardiomyopathy

Restrictive cardiomyopathy (RCMP) is characterized by restrictive filling and reduced diastolic volume of either or both ventricles with normal or near-normal systolic function and wall thickness. It may occur idiopathically or as a cardiac manifestation of systemic diseases such as scleroderma, amyloidosis, Churg-Strauss syndrome, cystinosis, sarcoidosis, lymphoma, Gaucher's disease, hemochromatosis, Fabry's disease, pseudoxanthoma elasticum, hypereosinophilic syndrome, carcinoid, Noonan's syndrome, reactive arthritis, or Werner's syndrome and various neuromuscular disorders. Whereas in idiopathic RCMP the therapeutic options are only treatment of cardiac congestion, in cases with an underlying disorder, a causal therapy may be available. Patients with RCMP should be investigated as soon as the cardiac diagnosis is established for extracardiac diseases to detect a possibly treatable cause of RCMP before the disease becomes intractable. These investigations include a diligent clinical history and examination, blood tests, and ophthalmologic, otologic, dermatologic, gastroenterologic, nephrologic, hematologic, and neurologic examinations. If extracardiac examinations do not reveal a plausible cause for RCMP, endomyocardial biopsy is indicated.

Familial restrictive cardiomyopathy with skeletal abnormalities

A family is described in which 5 of 9 living children were found to have restrictive cardiomyopathy associated with skeletal muscle and orthopedic abnormalities. In the absence of another identifiable etiology, a genetic cause for restrictive cardiomyopathy in this family is probable. Consistent with the poor prognosis encountered for children with restrictive cardiomyopathy, 2 children in this family died, whereas a third was symptomatic by age 3 years.

Diastolic heart failure: restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade: clinical and echocardiographic evaluation

An understanding of the basic principles of diastolic function is important in order to recognize diseases that may result in diastolic dysfunction and diastolic heart failure. Although uncommon, restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade are among the disorders that may affect primarily diastolic function with preservation of systolic function. Diastolic heart failure may manifest with chronic nonspecific symptoms or may present with acute hemodynamic compromise. Echocardiography plays a vital role in the diagnosis of diastolic dysfunction and differentiation of these disease processes. It also provides a basis for clinical decisions regarding management and surgical referral. This review summarizes the clinical features, pathophysiology, and hemodynamic and echocardiographic signs of restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade.

An approach to dissecting the congenitally malformed heart in the forensic autopsy: the value of sequential segmental analysis

The demonstration of congenital heart disease at autopsy necessitates the careful preservation and examination of the heart, the vessels, and their connections. Techniques preserving these connections and using a reproducible and systematic approach are preferred. The Rokitansky method of organ block dissection, in combination with a system of heart examination termed sequential segmental analysis, provides such an approach. This study is based on the examination of heart specimens accessioned into the Frank E. Sherman, M.D., and Cora C. Lenox, M.D., Heart Museum (containing approximately 2400 specimens) of the Pathology Department, Children's Hospital of Pittsburgh. Specimens received in consultation during a 25-year period from hospitals and coroners'/medical examiners' offices were examined, and the corresponding reports were reviewed. Of 46 total heart specimens examined (1975-1999), 29 (63%) were dissected properly or left intact for dissection at Children's Hospital of Pittsburgh, and 17 (37%) were incorrectly dissected for the demonstration of congenital heart disease. Of these 17 cases, 11 (24%) displayed dissection errors, which did not hinder a complete diagnosis, 3 cases (6.5%) had errors that enabled only an incomplete diagnosis, and in 3 cases (6.5%), no diagnosis of congenital heart disease could be made. Dissection mistakes and means of avoiding them are discussed. Review of medical and family history, external and internal examination, and a reproducible and sequential method of examining the heart and its connections enables documentation of even the most complex cardiovascular anomalies.

Idiopathic hypereosinophilic syndrome: magnetic resonance imaging findings in endomyocardial fibrosis

Significant eosinophilia and even eosinophilic tissue infiltration has been associated with a variety of clinical disorders including allergic and immunodeficiency states, drug reaction, infection, parasitic infestation and malignancy. Eosinophilia without an underlying aetiology and with multi-organ dysfunction has been designated idiopathic hypereosinophilic syndrome. We report a case of endomyocardial fibrosis with MRI findings.

Magnetic resonance imaging evaluation of myocardial and pericardial disease

Magnetic resonance imaging (MRI) has been shown to be an ideal noninvasive tool for imaging and diagnosing myocardial and pericardial diseases. In dilated and hypertrophic cardiomyopathy, MRI is suitable for the diagnosis and quantification of ventricular volume, stroke volume, and myocardial mass. Recent developments in the area of fast imaging techniques and MR contrast agents rapidly are increasing the utility of MRI for studying and assessing myocardial diseases. MRI may become a helpful technique with which to diagnose myocarditis and myocardial involvement in amyloidosis and sarcoidosis. Contrast-enhanced MRI also can be used for patients who have undergone heart transplantation to assess early signs of transplant rejection by improved contrast between normal and pathologic myocardium. For pericardial diseases, MRI provides an exact evaluation of the pericardial thickness, and it is a very sensitive technique for identifying pericardial effusions. Differentiation between hemorrhagic, serous, or chylous pericardial effusions usually can be made by using the typical signal behavior on T1-weighted and T2-weighted sequences. Due to its greater field of view and its ability to evaluate functionally the regional ventricular and atrial motion abnormalities in the typical tissue pattern, MRI has a significant potential in the evaluation of pericardial inflammation and constrictive pericarditis. J. Magn. Reson. Imaging 1999;10:617-626.

Cardiovascular manifestations of systemic autoimmune diseases

The systemic autoimmune diseases are a protean group of illnesses that primarily affect the joints, muscles, and connective tissue. All aspects of the cardiovascular system can be involved with clinical consequences ranging from asymptomatic abnormalities to serious life-threatening conditions. This article discusses the cardiovascular manifestations of the systemic autoimmune diseases with particular focus on clinical pathophysiology and management.

Echocardiographic Aspects of Restrictive Cardiomyopathy: Their Relationship with Pathophysiology

BACKGROUND AND METHODS: We studied 17 patients with restrictive cardiomyopathy; eight had biventricular restriction (type A), four had left ventricular restriction (type B), and five had only right ventricular restriction (type C). RESULTS: Type A disease was characterized by pulmonary and systemic venous congestion. The restrictive pattern was found in the inlet of both ventricles. Both atria were enormous, with small or normal-size ventricles. Differential diagnosis included constrictive pericarditis and systolic pump dysfunction. Type B restriction disease was characterized by venous pulmonary congestion, pulmonary hypertension, and important dilatation of the left atrium and right cavities with a small or normal-size left ventricle; the restrictive pattern was found only in the affected left ventricle. CONCLUSIONS: The clinical picture resembles that of rheumatic mitral valve disease with right ventricular failure. Type C disease had restriction only in the inlet of right ventricle, with giant right atrium, systemic venous hypertension with low flow, and normal pressure of pulmonary artery and left heart. Differential diagnosis included Ebstein's anomaly of tricuspid valve. The etiology of type A disease was amyloid, endomyocardial fibrosis of ventricles and idiopathic interstitial fibrosis. Asymmetric types were always caused by Davies' disease.

Idiopathic myocardial vasculitis presenting as restrictive cardiomyopathy

A previously unreported case of small-vessel myocardial vasculitis presenting as restrictive cardiomyopathy and congestive heart failure is described. The hemodynamic study, showing severely increased and equalized diastolic pressures in atrial and ventricular chambers, and cardiac MRI, showing normal pericardium and ventricular endomyocardial biopsy, not including myocardial vascular component, were insufficient to make a diagnosis. This made a thoracotomy and surgical cardiac biopsy necessary. Steroids and cyclophosphamide, introduced after histologic evidence of necrotizing vasculitis, unassociated with a systemic disease, became available and improved the clinical profile and the diastolic dysfunction at two-dimensional echocardiographic Doppler analysis.

Cardiac amyloidosis: Diagnostic features and clinical implications

Seven patients with cardiac amyloidosis were referred to King Khaled University Hospital. All patients in this study developed congestive heart failure. They had a long duration of illness and thickened ventricular wall with marked abnormalities in the left ventricular filling, and normal systolic function. Diastolic function is suggested as a possible mechanism of congestive cardiac failure in the patients presented.

Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis

BACKGROUND

Conventional cardiac catheterization criteria for the diagnosis of constrictive pericarditis (CP) rely on equalization of intracardiac pressures and have many recognized limitations. Recently, Doppler echocardiographic methods have been used to examine dynamic respiratory changes of increased ventricular interdependence and dissociation of intrathoracic and intracardiac pressures for the diagnosis of CP. These pathophysiological features may be best delineated by cardiac catheterization. Therefore, we studied the accuracy of these dynamic respiratory changes in left ventricular and right ventricular pressure for the diagnosis of CP at cardiac catheterization.

METHODS AND RESULTS

High-fidelity manometric catheters and respirometry were used to study 36 patients: 15 patients with surgically proven CP (group 1) and 21 patients with other causes of heart failure (group 2). Conventional cardiac catheterization variables used to establish the diagnosis of CP lacked sensitivity and specificity and failed to distinguish between these groups. However, the finding of discordance between right ventricular and left ventricular pressures during inspiration, a sign of increased ventricular interdependence, accurately distinguished patients in group 1 from those in group 2 (P < .05).

CONCLUSIONS

Examination of dynamic respiratory changes indicating increased ventricular interdependence may be helpful in the diagnosis of CP in the cardiac catheterization laboratory.

Usefulness of electron microscopy in the diagnosis of cardiac sarcoidosis

A 49-year-old man with cardiac sarcoidosis is presented. He suffered from congestive heart failure, and left ventricular asynergy and reduced function was evident by echocardiogram and left ventriculogram. A light microscopic examination of the endomyocardial biopsy revealed nonspecific myocarditis without giant cells or noncaseating granulomas. Under an electron microscope, however, several epithelioid cells were found in the specimen. The serum level of lysozyme was elevated. The patient had a past history of sarcoidosis of the eyes and lungs 22 years previously. Cardiac diseases presenting epithelioid cells other than sarcoidosis were clinically ruled out. Thus, the diagnosis of cardiac sarcoidosis was made based on both clinical and ultrastructural findings, and corticosteroid therapy was initiated. In the second biopsy, performed 4 months later, a noncaseating granuloma was found. Generally, the incidence of histological diagnosis of cardiac sarcoidosis by light microscopy is relatively low in endomyocardial biopsy specimens. The present case suggests that the addition of an ultrastructural examination may improve the diagnostic usefulness of the endomyocardial biopsy in cardiac sarcoidosis, since electron microscopy can clearly identify the presence of even one epithelioid cell.

Endomyocardial disease and eosinophilia

The authors discuss the hypereosinophilic syndrome:incidence, terminology, cytotoxicity, clinical presentation and diagnosis, prognosis, and treatment, and they provide a literature review.

The differentiation between restrictive cardiomyopathy and constrictive pericarditis: the impact of the imaging techniques

The differentiation between constrictive pericarditis and restrictive cardiomyopathy remains a difficult problem for clinical cardiologists. Recent advances in imaging techniques and the understanding of diastolic function have created a new diagnostic approach to this problem. In this article we will summarize the recent advances in the understanding of the pathophysiology of both disorders and how this is reflected mainly in the use of flow imaging techniques, such as Doppler echocardiography and radionuclide angiography. Combined with the advances in the radiological imaging of the pericardium by means of computed tomography and magnetic resonance imaging, an integrated approach to the differential diagnostic problem is proposed and an algorithm for clinical use has been designed.

Fatty infiltration: another restrictive cardiomyopathic pattern

Restrictive cardiomyopathies have been shown to occur as result of infiltrative processes from a variety of sources. The current report describes an obese male, who was found to have hemodynamic evidence of a restrictive cardiac process. His pericardium was proven to be normal and an incisional biopsy obtained of the myocardium during coronary artery bypass surgery demonstrated histologic evidence of fatty infiltration of myocardium. Review of the restrictive and pathology literature is discussed and indicates that this is the first report to demonstrate the association between fatty infiltration and hemodynamic findings consistent with a restrictive cardiomyopathy.