Primary restrictive cardiomyopathy. Non-tropical endomyocardial fibrosis and hypereosinophilic heart disease

Eosinophilic heart disease: diagnostic and prognostic assessment by cardiac magnetic resonance

AIMS 

Eosinophilic heart disease (EHD) is a rare cardiac condition with a wide spectrum of phenotypes. The diagnostic and prognostic value of cardiac magnetic resonance (CMR) in EHD remains unknown.

METHODS AND RESULTS 

This was a retrospective analysis of 250 patients with eosinophilia referred for a CMR scan (period 2000-2020). CMR data sets and clinical/laboratory data were collected. Patients were followed up for a mean of 24 months (range 1-224) for the composite endpoint of death, acute coronary syndrome, hospitalization for acute heart failure, malignant ventricular arrhythmias, or the need for implantable cardiac defibrillator/pacemaker. The main objectives were to explore the diagnostic value of CMR in EHD; relationships between cardiac function, late gadolinium enhancement (LGE), and EHD phenotypes; and the prognostic value of fibrosis and oedema by CMR. The prevalence of findings compatible with EHD was 39% (patients with cardiac symptoms: 57% vs. screening: 20%, P < 0.001). EHD phenotypes included subendocardial LGE (n = 58), mid-wall/subepicardial LGE (n = 26), pericarditis (n = 5) or dilated cardiomyopathy (n = 8). Myocardial oedema was present in 10% of patients. Intracardiac thrombi (7%) were associated with EHD phenotype (χ2=47.3, P = 1.3×10-8). LGE extent correlated with LVEDVi (rho = 0.268, P = 5.3×10-5) and LVEF (rho=-0.415, P = 8.6×10-11). A CMR scan positive for EHD [hazard ratio (HR) = 5.61, 95% confidence interval (CI): 1.82-17.89, P = 0.0026] or a subendocardial LGE pattern (HR = 5.13, 95% CI: 1.29-20.38, P = 0.020) were independently associated with the composite clinical endpoint.

CONCLUSION 

The diagnostic yield of CMR screening in patients with persistent eosinophilia, even if asymptomatic, is high. The extent of subendocardial fibrosis correlates with LV remodelling and independently predicts clinical outcomes in patients with eosinophilia.

Loeffler's Endocarditis and Hypereosinophilic Syndrome

Loeffler's endocarditis and hypereosinophilic syndromes are a unique group of infiltrative disorders characterized by hypereosinophilia, inflammatory thrombotic, and ultimately, fibrotic involvement of the heart leading to multiple complications including valve involvement, thromboembolic phenomena, heart failure. Clinical recognition, comprehensive laboratory and multimodality imaging diagnostic workup, and early initiation of treatment have been shown to slow down the progression and promote remission. This review addresses a detailed analysis of Loeffler's endocarditis and hypereosinophilic syndromes.

Association of the blood eosinophil count with end-organ symptoms

Introduction

Eosinophilia may cause organ dysfunction, but an exact relation between eosinophil blood counts and adverse outcomes has not been described. The aim of the study is to associate in one model both normal and increased blood eosinophil counts to the subsequent development of common conditions in internal medicine, in which eosinophil granulocytes may play a role for the symptoms.

Methods

From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 359,950 individuals with at least one differential cell count (DIFF) during 2000–2007. From these, one DIFF was randomly chosen. From the Danish National Patient Register we ascertained organ damage, within four years following the DIFF. Using multivariable logistic regression, odds ratios were calculated and adjusted for previous eosinophilia, sex, age, year, month, CRP and comorbid conditions.

Results

Risks for skin- and respiratory disease were increased from above the median eosinophil count of 0.16 × 10⁹/l and reached a plateau around 1.0 × 10⁹/l. Furthermore, risks of most outcomes also increased when the eosinophil count approached zero.

Conclusions

The observed U-shaped association with a plateau of risks around 1 × 10⁹/l indicates that the risk for symptoms due to eosinophilia do not increase proportionate at higher counts. This study demonstrates for the first time that there is indeed an increased risk below median count of 0.16 × 10⁹/l for an increased risk for the same manifestations. Clinically, it means that a normal or even low count of eosinophils do not rule out a risk for organ affection by eosinophils, and may contribute to explain, why patients may have normal eosinophil counts in e.g. asthma or allergy and still have symptoms from the lungs and skin, most likely explained by the extravasation of eosinophils.

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Blood eosinophilia may cause end-organ symptoms.

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An exact relation between eosinophil count and outcome has not been demonstrated.

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Eosinophil numbers correlate to organ damage even below the definition of eosinophilia.

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This association is U-shaped between organ manifestations and eosinophil count in blood.

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A plateau of risks is observed around 1 × 10⁹/l.

Endomyocardial fibrosis and myocardial infarction leading to diastolic and systolic dysfunction requiring transplantation

Endomyocardial fibrosis (EMF) is an endemic disease in tropical areas, characterized by restrictive physiology due to endocardial fibrous thickening of the ventricular chambers. We report the case of a 25-year-old man of African origin who presented with end-stage heart failure due to both diastolic and systolic dysfunction and extensive endocavitary thrombosis as proven by echocardiography and cardiac magnetic resonance. EMF diagnosis was confirmed by endomyocardial biopsy and the patient had eventually cardiac transplantation. The explanted heart revealed, besides features consistent with EMF, transmural post- myocardial infarction scarring, in the absence of significant coronary artery disease, most probably thromboembolic in origin.

Surgical Ventricular Septal Myectomy for Patients With Noonan Syndrome and Symptomatic Left Ventricular Outflow Tract Obstruction

Approximately 20% to 30% of patients with Noonan syndrome (NS) have asymmetric left ventricular hypertrophy (LVH) and LV outflow tract obstruction (LVOTO). The role of surgical myectomy in such patients is unknown. We sought to compare clinical features and outcomes of patients with NS and LVOTO with age- and gender-matched patients with nonsyndromic, obstructive hypertrophic cardiomyopathy (HC) after myectomy. Two cohorts were selected and retrospectively analyzed using Mayo Clinic databases from 1996 to 2014. Subjects included patients with NS with LVH and LVOTO and nonsyndromic controls with obstructive HC. Twenty-three patients with NS and LVH were identified, of whom 12 (8 males) underwent myectomy (10 septal and 2 combined septal/apical) for severe LVOTO (10 pediatric and 2 adults; 13 ± 10 year old [range 1 to 39]). Similar echocardiographic improvements were noted in both groups. There were no perioperative deaths. Residual gradients were slightly higher in patients with NS. No improvement was noted in left atrial volume after myectomy in patients with NS. At early follow-up, the majority showed improvement in the New York Heart Association class (88% in NS vs 82% in HC, median of 6 and 2 months, respectively). At late follow-up (median of 7 years), the survival rate was 92% in NS and 100% in HC. In patients with NS with LVH and symptomatic LVOTO, myectomy reduces both gradient and the New York Heart Association class, similar to patients with nonsyndromic obstructive HC. Residual gradients were slightly higher, and left atrial dilation persisted in patients with NS. In conclusion, myectomy should be considered in patients older than 1 year with NS and symptomatic LVOTO.

Hypereosinophilia-an unusual cause of multiple embolic strokes and multi-organ dysfunction

'Eosinophilia' can occur due to a large number of allergic, infectious, neoplastic, and idiopathic diseases. It can range in severity from a self-limiting condition to a life-threatening disorder. The term 'hypereosinophilia' refers to eosinophil levels >1500/μL, and regardless of the underlying cause can be associated with tissue and organ damage. 'Hypereosinophilic syndrome (HES)' is a rare disorder with sustained eosinophilia and multi-organ dysfunction in the absence of a discernable secondary cause. 'Undefined Hypereosinophilic Syndrome' is the most common type of primary hypereosinophilic diseases and we are reporting here one such case who presented with acute multiple embolic strokes secondary to biventricular apical thrombi and multi-organ dysfunction of a fulminant nature. This case highlights the limitation in current diagnostic criteria for HES and emphasizes the need for early intervention.

Hypereosinophilic syndrome associated with ulcerative colitis presenting with recurrent Loeffler's endocarditis and left ventricular thrombus treated successfully with immune suppressive therapy and anticoagulation

We reported a case of a 28-year-old Caucasian woman with hypereosinophilic syndrome (HES) associated with ulcerative colitis who presented on separate occasions with Loeffler's endocarditis. She was admitted in 2008 with fever, headache, confusion and visual loss. Diagnostic workup uncovered an eosinophilia of 3.1×10⁹/L and major ECG abnormalities. Subsequent echocardiography revealed left ventricular wall motion abnormalities with mural thrombus. MRI brain scan showed multiple white matter lesions consistent with acute infarcts. She recovered rapidly with corticosteroids and anticoagulation. Four years later she re-presented with headache, fatigue and an eosinophilia of 13.4×10⁹/L. This occurred 3 months after cessation of immunosuppression and within 12 months of total colectomy for fulminant ulcerative colitis. Echocardiography was suggestive of hypereosinophilic endomyocardial fibrosis with left ventricular thrombus. Anticoagulation and corticosteroids were resumed with good effect. This report highlights the findings, treatment and outcome of ulcerative colitis-associated HES manifesting as recurrent Loeffler's endocarditis.

Perimyocarditis and myocardial infarction: A rare manifestation of Churg-Strauss syndrome

The present article reports a case involving a 58-year-old man without cardiovascular risk factors who was admitted to hospital with acute coronary syndrome. Coronary angiography revealed high-grade arteriosclerotic stenosis of the mid-left anterior descending coronary artery and 80% proximal intermediate branch stenosis, which were treated using three drug-eluting stents. Churg-Strauss syndrome was diagnosed based on the patient's history of asthma, sinusitis, eosinophilia, nasal polyps, transient radiological pulmonary infiltrations and transient paresthesia over the left tibia, and eosinophilic pericardial effusion and eosinophilic infiltrations revealed in a myocardial biopsy. Treatment with prednisone was initiated, followed by treatment with cyclophosphamide. Eosinophil levels returned to normal after nine days of treatment. There is evidence that Churg-Strauss syndrome may promote arteriosclerosis.

A severe form of Churg-Strauss syndrome complicated with acute cardiac failure and rapidly progressive peripheral neuropathy--a possible effect of intravenous immunoglobulin therapy

We report a case of Churg-Strauss syndrome (CSS) complicated by severe cardiac failure and peripheral neuropathy. Two courses of methylprednisolone pulse therapy were unable to control the disease activity. Repeated intravenous administration of high-dose human immunoglobulin (IVIg) was added together with intravenous cyclophosphamide pulse therapy (IVCY), and the patient's cardiac function and neurological symptoms were gradually ameliorated without any adverse event. Although glucocorticoid and cyclophosphamide comprise the standard therapy for patients with CSS, a number of patients with severe complications appear to be resistant to such conventional treatment. IVIg is thought to be an effective therapeutic option for such patients.

Restrictive cardiomyopathies

Restrictive cardiomyopathies constitute a heterogenous group of heart muscle conditions that all have, in common, the symptoms of heart failure. Diastolic dysfunction with preserved systolic function is often the only echocardiographic abnormality that may be noted, although systolic dysfunction may also be an integral part of some specific pathologies, particularly in the most advanced cases such as amyloid infiltration of the heart. By far, the majority of restrictive cardiomyopathies are secondary to a systemic disorder such as amyloidosis, sarcoidosis, scleroderma, haemochromatosis, eosinophilic heart disease, or as a result of radiation treatment. The much more rare diagnosis of idiopathic restrictive cardiomyopathy is supported only by the absence of specific pathology on either endomyocardial biopsies or at post-mortem. Restrictive cardiomyopathy is diagnosed based on medical history, physical examination, and tests: such as blood tests, electrocardiogram, chest X-ray, echocardiography, and magnetic resonance imaging. With its wide availability, echocardiography is probably the most important investigation to identify the left ventricular dysfunction and should be performed early and by groups that are familiar with the wide variety of aetiologies. Finally, on rare occasions, the differential diagnosis from constrictive pericarditis may be necessary.

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.

Usefulness of echocardiography and doppler echocardiography in endomyocardial fibrosis

OBJECTIVE

Our goal was to demonstrate the usefulness of echocardiography and cardiac Doppler echocardiography (echo-Doppler) in the diagnosis of endomyocardial fibrosis, an unusual restrictive cardiomyopathy in Argentina.

METHODS

Between 1980 and 1998, we studied 10 women (aged 27 to 58 years) with endomyocardial fibrosis confirmed by surgery and/or endomyocardial biopsy. Of the 10 cases of endomyocardial fibrothrombosis, 8 were biventricular and 2 were left ventricular. Six patients had only an echocardiographic study, and the last 4 patients (after 1987) had an echo-Doppler study also; 3 had a transesophageal echocardiography examination as well. Seven patients had grade III-IV dyspnea, 2 had an edematous-ascitic syndrome, and 1 had right heart failure at the first examination. Four patients died of heart failure and 1 of overimposed sepsis. Surgery was successful in 2 patients with the biventricular form of the disease. In one of them, fibrotic decortication was performed in both ventricles together with tricuspid and mitral replacement. In the other, the right side was not surgically treated because of its mild engagement. One patient was lost to follow-up, and 3 patients are awaiting surgery at this writing.

RESULTS

In all 10 patients, echocardiography was the first diagnostic tool used. In M-mode echocardiography, the typical image showed the "square root" sign in the septum and posterior wall in addition to the "merlon" sign, characterized by a hypercontractile basal ventricle opposing an obliterated apex. In 2-dimensional echocardiography, inversion of the normal sized heart with obliterated ventricles and dilated atria were seen in the whole group. In 1 patient, the fibrous thrombus was limited to the apex of the right ventricle (Shaper's type 1) in a biventricular form, whereas in the left side of this patient and in the other 9 patients, the fibrous thrombus that initially occupied the apex engaged the posterior papillary muscle, pulling the posterior valve downward (Shaper's type 2) and generating tricuspid and/or mitral regurgitation that was always mild or moderate. The fibrous thrombus never altered the movement of the underlying myocardium. There were hypoechoic and hyperdense echoes inside the fibrotic material (the latter compatible with calcium), and in all 10 patients, different grades of pericardial effusion were found. Echo-Doppler showed the same minimal percentage of change in mitral and tricuspid velocities as found in healthy patients, which clearly differentiates endomyocardial fibrosis from constrictive pericarditis. Furthermore, a restrictive pattern was observed on both atrioventricular valves when both sides were engaged with a markedly short tricuspid deceleration time. Pulmonary veins showed a markedly diastolic D wave and a broad reversal A wave (the latter presented a low velocity when the wall of the left atrium was diseased) caused by an increased end-diastolic left ventricular pressure to the same extent throughout the respiratory cycle. Hepatic veins showed a markedly deep diastolic forward wave throughout the respiratory cycle and a marked reversal with inspiration.

CONCLUSIONS

We showed (1) echocardiographic studies of a significant number of patients with this unusual disease, (2) the characteristic diagnostic signs in M-mode and 2-dimensional echocardiography, and (3) the common echo-Doppler patterns shared by all subjects studied with this technique.

Long-term follow up of patients with endomyocardial fibrosis: effects of surgery

AIMS

To determine the long-term outcome of patients with endomyocardial fibrosis and to compare echocardiographic and haemodynamic data before and after ventricular endocardial resection.

PATIENTS

Seventeen patients (11 women and six men; mean age 35.5 years) diagnosed with endomyocardial fibrosis at the University Hospital in Zurich, Switzerland from 1971 to 1995. Twelve patients (70%) had partial obliteration of both ventricles and in five patients (30%) the fibrotic lesions were limited to the left ventricle.

METHODS

Fourteen of the 17 patients had surgical resection: fibrosis was resected from both ventricles in five patients and from the left ventricle only in nine patients. Ten patients had mitral valve replacement and two had tricuspid valve replacement. Left ventricle endocardial resection was done without reconstruction or replacement of the atrioventricular valve in three patients. Preoperative and postoperative echocardiographic data were available for 11 patients and haemodynamic data for six patients. Patients were followed up for 0.4-19 years (mean 8.6).

RESULTS

Preoperatively four patients were NYHA functional class IV and 10 were class III; postoperatively one patient was class III, seven class II, and six class I. Preoperatively, echocardiography showed obliteration of the left ventricular apex and inflow tract in all patients, which decreased or disappeared after surgery. Left ventricular end diastolic pressure decreased from 25 mm Hg before surgery to 14 mm Hg after successful resection of the fibrosis. Left ventricular and diastolic volume (normal 93 (17) ml/m2) increased from 65 ml/m2 to 97 ml/m2 (p < 0.05) after surgery. Ejection fraction was normal preoperatively (57%) and decreased slightly (52%) after surgery. One patient died five months after surgery from heart failure. Four surgically treated patients died during the follow up period: one each from systolic dysfunction, recurrence of endomyocardial fibrosis, pneumonia, and food poisoning. Overall survival was 65% at five years and 59% at 10 years; the survival rates of the operated patients was 72% and 68%, respectively. Only one of the medically treated patients survived longer than three years from diagnosis.

CONCLUSIONS

Endomyocardial fibrosis is a rare disease in European countries and is found mainly in women. The clinical picture is characterised by severe congestive heart failure but heart size is only moderately increased. Systolic performance is normal or only slightly depressed despite severe restriction to filling, atrioventricular valve regurgitation or both. Partial obliteration of the right and/or left ventricle may be detected by echocardiography. Endocardial resection with atrioventricular valve replacement is the treatment of choice with appreciable postoperative improvement and 10 year survival of approximately 70%.

Clonal eosinophilic disorders and the hypereosinophilic syndrome

An increase in the blood eosinophil count may occur in a number of disease states including allergies, parasitic infections, vascular disease and as a reaction to the presence of malignant tumours. This article defines those disorders that are not purely reactive, and describes in detail the diagnosis and features of clonal eosinophilic disorders and the hypereosinophilic syndrome. The clonal disorders that are associated with eosinophilia are discussed, in particular the acute and chronic eosinophilic leukaemias and clonal eosinophilias in association with acute myeloid leukaemia, myeloproliferative disorders and myelodysplastic syndromes. Whether eosinophilia is produced by a clonal or reactive disorder, the end result can often be the same, i.e. end organ damage produced by sustained hypereosinophilia in the presence of eosinophil activation. When no cause for the eosinophilia leading to the end organ damage is found, this disease is termed 'idiopathic hypereosinophilic syndrome'. Its pathogenesis, clinical features and management are discussed with particular reference to the possibility of it being a T-cell-associated disorder.

Atrio-ventricular regurgitations in constrictive pericarditis: incidence and post-operative outcome

We studied 33 surgically proven cases of constrictive pericarditis during the period 1989-1991 by color Doppler echocardiography and angiography to look for incidence and postoperative outcome of atrioventricular regurgitation. The mean age was 27.2 + 16.5 years (21 males, 12 females). There was a very high incidence of mitral (79%, trivial in 13, mild in 11 and moderate in 2) and tricuspid (73%, trivial in 7, mild and moderate in 6 each and severe in 5) regurgitation. There was good correlation between 'color Doppler' and angiography for detection and quantification of these regurgitations (r = 0.89 for mitral and 0.76 for tricuspid regurgitation, respectively). There were no preoperative clinical or hemodynamic predictors for the incidence or severity of these regurgitations. Immediate postoperative (7-10 days) evaluation by color Doppler did not show any change in these regurgitations. A follow-up study (by color Doppler and angiography) in 18 patients at a mean period of 229 + 105 days revealed regression of these regurgitations by at least 1 grade in 50% of patients. Patients with persisting regurgitations had persisting hemodynamic abnormality and relatively longer duration of symptoms. The presence of atrio-ventricular regurgitations should not be taken as evidence favoring diagnosis of restrictive cardiomyopathy and against that of constrictive pericarditis. The mechanism of these regurgitations is not clear to us.

Assignment of patients into the classification of cardiomyopathies

The original classifications of the cardiomyopathies based on anatomic criteria from radiographic and necropsy studies, as well as hemodynamic criteria from clinical and catheterization data, have been supplemented in recent years by information from noninvasive techniques. Echocardiography, radionuclide methods, and ambulatory ECG, in particular, have facilitated the ethical screening of family members and those less symptomatic than patients on whom the original classification was based. These powerful methods show a broad spectrum of anatomy and ventricular physiology along the natural history of and within the traditional categories of the cardiomyopathies. They also provide data on the effect of ventricular loading conditions affecting a range of diastolic filling patterns. This review has attempted to point out the areas of overlap among and/or controversy about the categories that have led us to a feeling of frustration when trying to neatly classify individual patients. The addition of filling patterns from Doppler echocardiography and nuclear angiography to the standard methods has been reviewed and hopefully will lend more perspective to the range of physiology seen in these conditions. The categories of cardiomyopathy should not be seen as excluding patients with the newly recognized variations in anatomy and ventricular filling patterns. Rather, the classification provides a framework on which to build and expand our understanding of these important conditions.

Constrictive pericarditis versus restrictive cardiomyopathy: a reappraisal and update of diagnostic criteria

Distinguishing constrictive pericarditis from restrictive cardiomyopathy is a difficult clinical challenge. We review published reports in which hemodynamic criteria were used to differentiate these two diagnoses. There were 82 cases of constriction and 37 cases of restriction. The overall predictive accuracy of the difference between right and left ventricular end-diastolic pressures (RVEDP and LVEDP), RV systolic pressure, and the ratio of RVEDP to RV systolic pressure were 85%, 70%, and 76%, respectively. If all three criteria were concordant, the probability of having correctly classified the patient was greater than 90%. However, one fourth of patients could not be classified by hemodynamic criteria. There are few data to support the use of hemodynamic measurements after exercise or volume infusion to separate these two groups. Numerous recent studies have reported on the ability of left ventriculography, Doppler echocardiography, or radionuclide angiography to distinguish constriction from restriction. Many of the proposed indices appear promising, but these studies suffer from small sample size, potential selection bias, and complexity of the proposed criteria, which have limited their widespread application. New imaging technologies, such as CT scanning or MRI have been applied in a limited number of cases, but appear to be a sensitive means of detecting abnormal pericardium. Endomyocardial biopsy has proven useful in establishing the diagnosis of infiltrative cardiomyopathies, eliminating in those cases the need for surgical intervention. The finding of myocarditis must be considered a nonspecific finding that does not preclude thoracotomy. Since constrictive pericarditis is a surgically curable condition, the distinction between constrictive and restrictive disease is of critical importance. Taking into account the relative contribution of data derived from hemodynamic, imaging,and biopsy studies, we propose an algorithm for the selection of appropriate candidates for pericardial biopsy and stripping.

Restrictive cardiomyopathy following acute myocarditis--a case report

A fifty-five-year-old man developed intractable heart failure four weeks after upper respiratory infection. His central venous pressure was as high as 300 mmH2O. Two-dimensional echocardiogram revealed no muscular hypertrophy of the ventricles, no pericardial thickness, and no pericardial effusion. On catheterization, hemodynamic data were compatible with restrictive cardiomyopathy. Transvenous endomyocardial biopsy of the left ventricle was performed. Histologic examination strongly suggested that cardiomyopathy developed after acute myocarditis.

Cardiac involvement in Churg-Strauss syndrome shown by echocardiography

To define the range of cardiac involvement in the Churg-Strauss syndrome, M mode, continuous wave Doppler, and cross sectional echocardiograms were recorded in twelve patients with the disorder. The M mode recordings were digitised and the cross sectional images were recorded with standardised gain settings to determine regional myocardial echo amplitude. Left ventricular end diastolic and end systolic dimensions were increased above the normal 95% confidence interval in four patients, three of whom showed a depressed shortening fraction. Mitral regurgitation was present in six patients; this was severe enough to need valve replacement in two. Mean echo amplitude in both the septum and the posterior wall was significantly increased above normal by a mean (SD) of 4.87 (2.57) dB, suggesting the presence of myocardial fibrosis. There was no evidence of subendocardial involvement as there is in other hypereosinophilic syndromes. Mitral regurgitation is common in the Churg-Strauss syndrome. This cannot be ascribed to involvement of the cusps or chordae and it occurs even when ventricular function is well preserved. It is suggested that mitral regurgitation is caused by diffuse myocardial fibrosis.

Demonstration of restrictive ventricular physiology by Doppler echocardiography

In patients with restriction of cardiac filling of various origins, cardiac catheterization has been traditionally used as part of the diagnostic evaluation to verify the presence of restrictive/constrictive hemodynamics. In an attempt to determine whether this "restrictive" physiology could be demonstrated noninvasively, 14 patients who had a history, physical examination, two-dimensional echocardiogram and catheterization data compatible with a restrictive myocardial process were studied with pulsed wave Doppler ultrasound. Forty normal subjects served as a control group. The Doppler ultrasound evaluation included measurement of peak mitral and tricuspid flow velocities and flow velocity integrals, mitral and tricuspid deceleration times and central venous flow patterns during apnea and inspiration. The flow velocity recordings across the mitral and tricuspid valves in patients manifesting restriction were markedly different from those in normal subjects, showing shortened deceleration times across both valves, which indicated both an abrupt premature cessation of ventricular filling and the presence of a diastolic dip-plateau contour in ventricular pressure recordings. In addition, abnormal central venous flow velocity reversals with inspiration and diastolic mitral and tricuspid regurgitation were frequently observed, also suggesting the reduced myocardial compliance characteristic of a restrictive myocardial process.

The idiopathic hypereosinophilic syndrome

A 14 year old girl with idiopathic hypereosinophilic syndrome is described. In addition to weight loss, anaemia, amenorrhoea, general lethargy, anorexia, mouth ulcers, blisters of hands and feet, and petechial skin rash, she had features of involvement of the cardiovascular system as the major complication. She responded well to treatment. After a comprehensive search of the published reports 18 cases of this syndrome were identified in children under 16 years. Fifteen of these children had involvement of the cardiovascular system as the major source of their morbidity and mortality. Summary of the clinical details and laboratory, biopsy, and necropsy findings of the involvement of the various organ systems of the 18 children is presented.

Eosinophilic heart disease presenting with features suggesting hypertrophic obstructive cardiomyopathy

We report a 25-year-old female with characteristic features of eosinophilic heart disease on clinical presentation, echocardiography, cardiac catheterization, and LV endomyocardial biopsy. Concomitant physical examination and echocardiographic findings suggesting hypertrophic obstructive cardiomyopathy resolved during treatment with anticoagulation and prednisone therapy.

Cardiomyopathy. 2. Hypertrophic and restrictive/obliterative types

The functional classification of the three types of cardiomyopathy has been helpful in organizing practitioners' thinking. The past three decades have witnessed tremendous advances in understanding of the pathophysiology, clinical and laboratory diagnosis, and treatment of these disorders. New doors of exploration are opening to answer such nagging questions as whether medical therapy alters long-term survival rates in dilated (congestive) cardiomyopathy, whether immunologic therapy will alter the course of dilated or restrictive/obliterative cardiomyopathy, and whether genetic manipulation or in utero therapy will prevent hypertrophic cardiomyopathy. The goals of effective treatment in all these disorders remain the same: amelioration of symptoms, prevention of sudden death, and constraint or resolution of the basic disease process. Achieving these goals requires a multidisciplinary approach, involving cardiologists, surgeons, immunologists, geneticists, cell biologists, virologists, and pathologists. Prospects are that one day treatment will no longer be an imprecise, palliative art but a definitive, curative science.

Clinical, hemodynamic and endomyocardial biopsy findings in idiopathic restrictive cardiomyopathy

Restrictive cardiomyopathy is uncommon and in its overt form is associated with heart failure, characterized primarily by abnormalities in diastolic function and preserved or nearly preserved systolic function. It may be associated with amyloidosis, hemochromatosis or endomyocardial fibrosis. We describe five patients with restrictive cardiomyopathy, ages ranging from 35 to 71 (mean 49), three of whom were men. Fatigue, dyspnea on exertion and chest pain were the most frequent symptoms. Only one patient had overt heart failure, and three had normal or near-normal hemodynamics at rest that became greatly abnormal with exercise. Four of the five patients are alive now 9 to 77 (mean 33) months following the onset of symptoms. Despite prior emphasis on specific causes, restrictive cardiomyopathy in this series had no definable cause. Moreover, the presence of a "latent" form of restriction (abnormalities only with exercise) suggests that the incidence of the disease may be higher than previously appreciated.

Myocarditis and cardiomyopathy in the dog and cat

Myocarditis and cardiomyopathy were diagnosed in 36 dogs from 11 litters, and myoendocarditis and restrictive cardiomyopathy were diagnosed in 51 cats. Most of the dogs and cats died unexpectedly. Spontaneous parvoviral infection in the dogs caused acute (myocytolysis with presence of intranuclear inclusion bodies in the myocytes), subacute (inflammatory reaction and myocytolysis), and chronic (fibrosis and myocytolysis) myocarditis, which led to extensive myocardial fibrosis and abnormality of the myocytes, similar to dilated cardiomyopathy in man. Spontaneous acute, subacute, and chronic myoendocarditis in the cats led to granulation, extensive fibrosis, and necrosis of the myoendocardium, i.e., like restrictive cardiomyopathy which occurs in man without eosinophilia. Thus, the dog and cat are important animal models of primary myocardial disease.

Clinical spectrum and endomyocardial biopsy findings in eosinophilic heart disease

Fourteen cases of heart disease with hypereosinophilia were analyzed employing conventional cardiologic methods, including echocardiography, cardiac catheterization, and endomyocardial biopsy. The cases were divided into four types: Acute carditic (endocarditis, myocarditis, pericarditis; five cases); ventricular dilation (three cases); restrictive (three cases); electric disturbance (three cases). Biopsy revealed significant changes in all cases. In one case of the ventricular dilation type, endomyocardial fibrosis with myocardial degeneration was seen, and in another case mural thrombus formation was shown to be present. In three cases of the restrictive type, endomyocardial fibrosis (EMF) was observed. In two cases of the electric disturbance type, minor right ventricular myocardial degeneration was observed. In two of the three cases of the carditic type and in three of eight cases in other categories, postmyocarditic changes were observed. The course of the disease compared with the type of disorder revealed a short course in the carditic type and a longer course, ranging from 2 to 24 years, with one exception, in the other types. It is also confirmed that the various histopathologic changes can be related to particular clinical presentations. We have shown that the basic changes in eosinophilic heart disease are not restricted to the endomyocardium and that they occur in various parts of the heart causing more widespread manifestations. The more comprehensive term "eosinophilic heart disease" is a preferable description.

Endomyocardial biopsy: a review of the literature

A review of the literature relating to endomyocardial biopsy (EMB) is presented. This is considered important at this time since EMB is being utilized with increasing frequency, particularly for the diagnosis of myocarditis. The development of the technique is briefly outlined. Emphasis is placed on the clinical application of EMB in the various primary cardiomyopathies (dilated, hypertrophic, restrictive, and obliterative), the infiltrative secondary cardiomyopathies (amyloidosis, sarcoidosis, hemochromatosis), myocarditis, as well as such conditions as adriamycin cardiotoxicity, cardiac transplant rejection, and Kawasaki disease. More controversial application of EMB in primary mitral valve prolapse (Barlow's syndrome), idiopathic ventricular arrhythmias, and the elucidation of the enigmatic finding of angina with angiographically normal coronary arteries is detailed. Experience with immunological and biochemical investigation of biopsy material, as well as with virus isolation and drug assays in the myocardium, is alluded to. Complications encountered with this procedure are also discussed, and its future role is contemplated.

Idiopathic restrictive cardiomyopathy

This report details the clinical, hemodynamic, and morphologic data from four patients 59 to 77 years old (mean 66) with a primary restrictive cardiomyopathy. All patients had symptoms of congestive heart failure, jugular venous distention, and murmurs of mitral and tricuspid regurgitation. Four patients required pacemakers, three for the brady-tachy syndrome and one for complete heart block. Chest x-ray demonstrated cardiomegaly in all four patients and pulmonary congestion and/or pleural effusions in three. Echocardiographic examination documented left atrial enlargement in all patients, along with normal left ventricular internal dimensions. Global left ventricular systolic function was normal in all, and left and right ventricular filling pressures were elevated and similar in three. A dip and plateau pattern was present in the pressure tracings of two of three patients. Unlike previous reports of restrictive cardiomyopathy, in our four patients there was no specific morphologic cause noted at necropsy. Pathologic evaluation demonstrated biatrial dilatation in all patients, with thrombi present in the atrial appendages in three. Normal ventricular cavity size and mild right ventricular hypertrophy were present in all patients and mild-to-moderate left ventricular hypertrophy was present in two. There were no significant pericardial, endocardial, or valvular abnormalities and no infiltrative myocardial disorders were present. Light and electron microscopic studies demonstrated only interstitial fibrosis of the myocardium. A restrictive hemodynamic profile may be observed in the absence of specific infiltrative disorders and affected patients may exhibit a prolonged clinical course of 4 to 14 years (mean 9). However, in these patients congestive heart failure responded poorly to medical therapy or surgical correction of valvular regurgitation, which is common in this disorder.

Phonomechanocardiographic findings in endomyocardial fibrosis

Endomyocardial fibrosis (EMF) is a severe restrictive cardiomyopathy characterized by the formation of fibrous tissue on the endocardium and to a lesser extent in the myocardium of one or both ventricles. The disease results in endocardial rigidity, atrioventricular valve dysfunction and progressive obliteration of the ventricular cavity. The clinical and pathological findings of EMF have been well established and definitive diagnosis can be made by selective cineangiocardiography. However, there are few reports concerning the phonomechanocardiographic (PMCG) patterns in this condition. In this paper we describe the PMCG findings in 12 patients with EMF which is now recognized with increasing frequency in the Northeast of Brazil.

Electron microscopic changes in tropical endomyocardial fibrosis

Electron microscopic examination of cardiac tissue from seven patients with tropical endomyocardial fibrosis showed the endocardium to be replaced by maturing granulation tissue containing haphazardly arranged collagen bundles, smooth muscle cells, blood vessels and degranulated mast cells. Mature collagen was present on the luminal aspect of the granulation tissue. Myofibres showed mitochondrial swelling, lamella bodies, focal myocytoplasmic clearing and collapsed intercalated discs. Small calibre blood vessels exhibited endothelial swelling, areas of basement membrane duplication and collections of neutrophilic and eosinophilic leucocytes. Eosinophils showed alteration in granule morphology. These changes are similar to the lesions reported in endomyocardial disease with eosinophilia.

Echocardiographic features of tropical endomyocardial disease in South India

Fifteen patients with tropical endomyocardial disease which had been proved angiographically were studied using M-mode and cross-sectional echocardiography to determine the extent to which specific features of this disease could be recognised by these non-invasive methods. Tethering of the posterior mitral valve leaflet to the ventricular wall in combination with areas of echo-dense material in the posterior left ventricular wall and associated papillary muscle appeared to be a constant diagnostic feature of this disease. Colour coding of regional echo amplitude showed high intensity echoes in a distribution corresponding closely to that of the fibrosis known to occur in this condition. Though M-mode echocardiography did not contribute diagnostic information, it was useful in defining the functional consequences of myocardial or mitral valve disease. Digitisation of records allowed a restrictive pattern of left ventricular filling to be observed. It was concluded that cross-sectional echocardiography, particularly when supplemented by colour coded amplitude processing, can make a confident non-invasive diagnosis of tropical endomyocardial disease and so could be useful in assessing its progression or response to treatment.

Value of two-dimensional echocardiography in endomyocardial disease with and without eosinophilia. A clinical and pathologic study

Ten patients (six women and four men) with endomyocardial disease, four with and six without hypereosinophilia, were studied by two-dimensional echocardiography (2-D echo). Eight had biventricular congestive heart failure and two had atypical chest pain with ischemic electrocardiographic changes. The patients were 15-50 years old (mean 40 years) and duration of illness was 2-9 years (mean 4.4 years). Nine had cardiac catheterization and three pathologic examination. Characteristic 2-D echo findings included apical obliteration of one or both ventricles by echogenic material suggestive of fibrosis or thrombosis; bright, specular echoes at the cavity surface of the apical obliteration suggesting patchy calcification; preserved left apical systolic inward motion, which differed significantly from the dyskinetic motion of thrombotic apical obliteration of ischemic or Chagasic origin (p less than 0.001); involvement of the papillary muscles and posterior atrioventricular valve; preserved ventricular contractile function in most patients; and the combination of normal-to-small ventricles with large atria. None of 14 subjects with secondary hypereosinophilia followed for 15.4 months developed similar 2-D echo findings. We conclude that both forms of endomyocardial disease had a 2-D echo pattern useful for noninvasive recognition and differentiation from patients who have valvular heart disease, constrictive pericarditis and cardiomyopathies of other origins.

Endomyocardial fibrosis in Africa

Endomyocardial fibrosis (EMF) is a disease of the rain-forest belt in Africa. There is general agreement as to its pathology in the acute phase, but this is difficult to diagnose clinically. The aetiology is still unknown although there are reports which suggest that eosinophilic endomyocardial disease may be the cause. Further studies are needed to define EMF in its acute stage and find out how chronic EMF evolves. A longitudinal study on young people with eosinophilia and a comparative study of two villages, one in an endemic zone and the other in a zone where EMF is uncommon, will also be helpful in identifying its cause. The most promising form of treatment at present is surgical.

Endomyocardial disease in South America--report on 23 cases in Venezuela

Twenty-three cases of endomyocardial disease (ED) are presented, studied in Venezuela, a tropical country in northern South America. The diagnosis was confirmed in 18 cases by means of pathological studies, and in 5 cases by angiocardiography which showed the characteristic obliterative ventricular lesions. Eosinophilia was present in 35% of the patients. The most frequent clinical feature was heart failure associated with mitral regurgitation. Systemic embolism was the first clinical feature in 5 cases. In 2 cases, ED was associated with autoimmune haemolytic anaemia or vasculitis. Necropsy revealed a predominance of the left-sided (9/16 cases) and biventricular (6/16 cases) types. The pathological lesions were characterised by fibrous thickening of the endocardium at the apex and the ventricular inflow tracts extending to the myocardium and involving the atrioventricular valves. ED is frequently misdiagnosed as rheumatic valvular cardiopathy. The two-dimensional echocardiogram is a very useful procedure for determining the spatial anatomy of ED. The echo findings were closely correlated with ventriculographic and necropsy findings. Even though ED is widely spread around the world, it is most frequently found in tropical and subtropical countries in Africa, Asia and America, such as Venezuela and Brazil. This suggests that there are aetiological factors in these latitudes, about which little is known.