Pitfalls in diagnosis and clinical, echocardiographic, and hemodynamic findings in endomyocardial fibrosis: a 25-year experience

Endomyocardiofibrosis in the Americas Collaborative Study: The EMF-SIAC Registry

Endomyocardiofibrosis (EMF) is a restrictive cardiomyopathy characterized by subendocardial fibrosis due to eosinophilic myocardial infiltration. EMF may commonly present with heart failure (HF) or atrial fibrillation (AF). Immunosuppression can be effective in early stages, but not in the chronic phase. Our objective was to describe the characteristics of EMF patients in the Americas. This registry is a retrospective multicenter cross-sectional study including patients ≥18 years-old with EMF diagnosed by imaging methods, according to the Mocumbi criteria. Clinical, biochemical, and imaging variables were analyzed. On the 54 patients included, 28 (52%) were male with an age of 47 years. The etiology was idiopathic in 47 (87%) patients, familial in 4 (7%), and secondary to chemotherapy in 2 (3.5%). We detected a history of HF in 41 patients (76%), AF in 19 (35%), and ischemic stroke in 8 (15%). The diagnosis was made by echocardiography in all patients, and 38% had Cardiac Resonance or Computed Tomography. Thirty-five patients (65%) presented a left ventricular ejection fraction ≥50%, 11 (21%) severe mitral regurgitation, and 18 (33%) severe tricuspid regurgitation. In 17 patients (32%) the diagnosis was confirmed by endomyocardial biopsy. Among medical therapy, 72% received beta-blockers, 63% vasodilators, 65% mineralocorticoid antagonists, 7.4% SGLT2 inhibitors, and 11% corticosteroids. Subendocardial resection was performed in 9 (16%) patients and mitral valve replacement in 11 (20%) patients. In conclusion, EMF patients had a high prevalence of HF, AF, and embolic events. The diagnosis was frequently made in an advanced stage when HF management and surgery were the only effective treatments.

Intracardiac mass revealing a rare form of cardiomyopathy

We present the case of a woman with a 2-month history of exertional dyspnoea and fatigue in which echocardiography revealed a cavity-obliterating right ventricular mass. Further imaging evaluation using cardiac magnetic resonance showed a thrombotic mass as well as diffuse myocardial oedema and endomyocardial fibrosis (EMF) that involved both ventricles. In the absence of any other cause (including peripheral eosinophilia), the diagnosis of idiopathic EMF was established. This case highlights this uncommon disease in non-tropical areas.

Endomyocardial fibrosis: past, present, and future

Endomyocardial fibrosis (EMF) is a neglected idiopathic disorder, predominant in tropical and subtropical regions of the developing world. It is characterized by fibrotic thickening of the endocardium and myocardium of one or both ventricles. EMF was an important cause of heart failure which accounted for up to 20% of the cases in endemic areas of Africa (rural community in Mozambique), but during the last few years, incidents of the disease have decreased considerably. Although its pathogenesis and etiology are not fully understood, its pathology resembles conditions such as eosinophilic cardiomyopathy and hypereosinophilic syndrome. Extensive fibrosis of the ventricular endocardium causing architectural distortion, impaired filling, and valvular insufficiency defines the disease. Confined to peculiar and limited geographical areas, the etiology remains blurred and it carries a grim prognosis. Medical care currently remains very challenging as one-third to half of patients with an advanced disease die within 2 years. Surgery in the correct setting can increase survival and especially in patients with advanced heart failure.

Endomyocardiofibrosis: A Systematic Review

Endomyocardiofibrosis was described first time in Uganda as an infrequent restrictive cardiomyopathy with a poor prognosis, characterized by fibrosis of the ventricular subendocardium and severe restrictive physiology leading to difficult therapeutic management and frequently associated with hypereosinophilic syndrome. Its higher prevalence in the tropics and its relationship in some cases with hypereosinophilic endocarditis has led to the search for genetic, infectious, autoimmune and nutritional causes, but its etiology remains unclear. It is a rare cardiomyopathy, difficult to diagnose and with a nonexistent effective treatment. Imaging methods such as echocardiography and cardiac magnetic resonance are essential for the initial diagnosis, although endomyocardial biopsy establishes the definitive diagnosis. Immunosuppressive treatment is only useful in the early stages of the disease and usually ineffective if installed late when signs of heart failure are present. Surgical treatment is generally palliative.

Comprehensive Assessment of Endomyocardial Fibrosis with Cardiac MRI: Morphology, Function, and Tissue Characterization

Endomyocardial fibrosis (EMF) affects approximately 12 million persons worldwide and is an important cause of restrictive cardiomyopathy in the developing world, with the highest prevalence reported in sub-Saharan Africa, South Asia, and South America. EMF is characterized by apical filling with fibrotic tissue of one or both ventricles, often associated with thrombus, calcification, and atrioventricular valve regurgitation, leading to typical symptoms of restrictive heart failure. Transthoracic echocardiography (TTE) is the first-line modality for assessment of EMF, basically owing to its widespread availability. However, in recent years cardiac MRI has emerged as a powerful tool for assessment of cardiac morphology and function, with higher accuracy than TTE, along with the unique advantage of being able to provide comprehensive noninvasive tissue characterization. Delayed enhancement (DE) imaging is the cornerstone of cardiac MRI tissue characterization and allows accurate identification of myocardial fibrosis, conveying valuable additional diagnostic and prognostic information. The typical DE pattern in EMF, described as the "double V" sign, consists of a three-layered pattern of normal myocardium, thickened enhanced endomyocardium, and overlying thrombus at the apex of the affected ventricle; it has excellent correlation with histopathologic findings and plays an important role in differentiating EMF from other cardiomyopathies. Conversely, fibrous tissue deposition quantified using DE imaging, when indexed to body surface area, has been shown to be a strong independent predictor of mortality. The aim of this review is to summarize state-of-the-art applications of cardiac MRI for diagnostic and prognostic assessment of patients with suspected or confirmed EMF. Online supplemental material is available for this article. ^©RSNA, 2020.

A case report of a 40-year-old woman with endomyocardial fibrosis in a non-tropical area: from initial presentation to high urgent heart transplantation

Background

Endomyocardial fibrosis (EMF) represents the most common cause of restrictive cardiomyopathy worldwide. Despite a high prevalence in tropical regions, it occasionally occurs in patients who have never visited these areas. While researches have proposed various possible triggers for EMF, etiology and pathogenesis remain largely unknown. Diagnosis is based on patient history, heart failure symptoms, and echocardiographic signs of restrictive ventricular filling, atrioventricular valve regurgitation and frequently apical thrombus. Following is a case report of an Austrian patient with EMF who eventually had to undergo a heart transplant. This case report strives to promote awareness for this in non-tropical areas uncommon but nevertheless detrimental disease.

Case presentation

A 40-year-old woman was presented at our emergency department with chest pain and fever up to 38.1° Celsius. Plasma troponin-T levels and inflammatory markers were slightly elevated, but the echocardiogram was without pathological findings. The patient was hospitalized on the suspicion of acute myocarditis and discharged soon after improvement. Eight months later, she was presented again with chest pain and symptoms of heart failure. The echocardiogram showed normal systolic left ventricular (LV) function with LV wall thickening and severe restrictive mitral regurgitation as well as aortic and tricuspid regurgitation. Coronary angiogram was normal but right heart catheterization showed pulmonary hypertension due to left heart disease. Further diagnostic workup with cardiac magnetic resonance imaging revealed subendocardial late enhancement and apical thrombus formation in the left ventricle compatible with the diagnosis of EMF. A comprehensive diagnostic workup showed no evidence of infection, systemic immunologic or hematological disease, in particular hypereosinophilic syndrome. After a multidisciplinary consideration of several therapeutic options, the patient was listed for heart transplantation. On the waiting list, she deteriorated rapidly due to progressive heart failure and finally underwent a heart transplantation. Histological examination confirmed the diagnosis of EMF. Six years after her heart transplantation, the patient was presented in an excellent clinical condition.

Conclusions

Even in non-tropical regions, the diagnosis of EMF should always be considered in restrictive cardiomyopathy. Knowledge of the distinct phenotype of EMF facilitates diagnosis, but comprehensive workup and therapeutic management remain challenging and require a multidisciplinary approach.

Endomyocardial fibrosis in Sudan: clinical and echocardiographic features

Objective:

Endomyocardial fibrosis (EMF) is a rare disease and is often an underdiagnosed and forgotten cardiomyopathy. The objective of this study was to document the current frequency of EMF in Sudan by defining and selecting cases from patients attending the echocardiography laboratory. Additionally we aimed to create an EMF registry for Sudan.

Methods:

The study started in January 2007 and is on-going. All the patients attending our echocardiography clinics in four different hospitals in Khartoum, Sudan, were included. Transthoracic echocardiography was used as the main diagnostic and selection tool. The diagnosis of EMF was based on predefined criteria and definitions, and was further supported by additional clinical, ECG, laboratory and chest X-ray findings.

Results:

Out of 4 332 cases studied, 23 (0.5%) were found to have features of EMF. Females constituted 52% and the age range was 24 to 67 years. All patients presented with dyspnoea grades III–IV. Advanced heart failure with gross fluid overload was seen in 54% of cases and ascites was seen in 30%. EMF was biventricular in 53%, left ventricular in 29% and right ventricular in 18% of cases. Apical and ventricular wall fibrosis was found in all cases, followed by atrial enlargement, atrioventricular valve incompetence, ventricular cavity obliteration, restrictive flow pattern and pericardial effusion. Additional echocardiographic features are defined and discussed.

Conclusion:

Although a rare disease, cases of EMF can be identified in Sudan if a high index of suspicion is observed. New echocardiographic features of ventricular wall layering, endocardial fibrous shelf and endomyocardiopericarial fibrosis were identified and are discussed.

Coronary Microcirculatory Dysfunction in Human Cardiomyopathies: A Pathologic and Pathophysiologic Review

Cardiomyopathies are a heterogeneous group of diseases of the myocardium. The term cardiomyopathy involves a wide range of pathogenic mechanisms that affect the structural and functional states of cardiomyocytes, extravascular tissues, and coronary vasculature, including both epicardial coronary arteries and the microcirculation. In the developed phase, cardiomyopathies present with various clinical symptoms: dyspnea, chest pain, palpitations, swelling of the extremities, arrhythmias, and sudden cardiac death. Due to the heterogeneity of cardiomyopathic patterns and symptoms, their diagnosis and therapies are great challenges. Despite extensive research, the relation between the structural and functional abnormalities of the myocardium and the coronary circulation are still not well understood in the various forms of cardiomyopathy. The main pathological characteristics of cardiomyopathies and the coronary microcirculation develop in a progressive manner due to (1) genetic-immunologic-systemic factors; (2) comorbidities with endothelial, myogenic, metabolic, and inflammatory changes; (3) aging-induced arteriosclerosis; and (4) myocardial fibrosis. The aim of this review is to summarize the most important common pathological features and/or adaptations of the coronary microcirculation in various types of cardiomyopathies and to integrate the present understanding of the underlying pathophysiological mechanisms responsible for the development of various types of cardiomyopathies. Although microvascular dysfunction is present and contributes to cardiac dysfunction and the potential outcome of disease, the current therapeutic approaches are not specific for the given types of cardiomyopathy.

Inflammatory Cardiomyopathic Syndromes

Inflammatory activation occurs in nearly all forms of myocardial injury. In contrast, inflammatory cardiomyopathies refer to a diverse group of disorders in which inflammation of the heart (or myocarditis) is the proximate cause of myocardial dysfunction, causing injury that can range from a fully recoverable syndrome to one that leads to chronic remodeling and dilated cardiomyopathy. The most common cause of inflammatory cardiomyopathies in developed countries is lymphocytic myocarditis most commonly caused by a viral pathogenesis. In Latin America, cardiomyopathy caused by Chagas disease is endemic. The true incidence of myocarditis is unknown to the limited utilization and the poor sensitivity of endomyocardial biopsies (especially for patchy diseases such as lymphocytic myocarditis and sarcoidosis) using the gold-standard Dallas criteria. Emerging immunohistochemistry criteria and molecular diagnostic techniques are being developed that will improve diagnostic yield, provide additional clues into the pathophysiology, and offer an application of precision medicine to these important syndromes. Immunosuppression is recommended for patients with cardiac sarcoidosis, giant cell myocarditis, and myocarditis associated with connective tissue disorders and may be beneficial in chronic viral myocarditis once virus is cleared. Further trials of immunosuppression, antiviral, and immunomodulating therapies are needed. Together, with new molecular-based diagnostics and therapies tailored to specific pathogeneses, the outcome of patients with these disorders may improve.

Tropical Endomyocardial Fibrosis: Natural History, Challenges, and Perspectives

Tropical endomyocardial fibrosis (EMF) is a neglected disease of poverty that afflicts rural populations in tropical low-income countries, with some certain high-prevalence areas. Tropical EMF is characterized by the deposition of fibrous tissue in the endomyocardium, leading to restrictive physiology. Since the first descriptions in Uganda in 1948, high-frequency areas for EMF have included Africa, Asia, and South America. Although there is no clear consensus on a unified hypothesis, it seems likely that dietary, environmental, and infectious factors may combine in a susceptible individual to give rise to an inflammatory process leading to endomyocardial damage and scar formation. The natural history of EMF includes an active phase with recurrent flare-ups of inflammation evolving to a chronic phase leading to restrictive heart failure. In the chronic phase, biventricular involvement is the most common presentation, followed by isolated right-sided heart disease. Marked ascites out of proportion to peripheral edema usually develops as a typical feature of EMF. EMF carries a very poor prognosis. In addition to medical management of heart failure, early open heart surgery (endocardectomy and valve repair/replacement) appears to improve outcomes to some extent; however, surgery is technically challenging and not available in most endemic areas. Increased awareness among health workers and policy makers is the need of the hour for the unhindered development of efficient preventive and therapeutic strategies.

Apical hypertrophic cardiomyopathy with hemodynamically unstable ventricular arrhythmia - Atypical presentation

We present a patient with asymptomatic apical hypertrophic cardiomyopathy (AHCM) who recently developed cardiac arrhythmias, and shortly discuss the diagnostic modalities, differential diagnosis, and treatment strategy for this condition. AHCM is a rare form of hypertrophic cardiomyopathy, which usually involves the apex of the left ventricle. AHCM can occur with varied presentations such as chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation, and congestive heart failure. The most peculiar electrocardiogram findings are giant T-waves inversion in the precordial leads with left ventricular (LV) hypertrophy. A transthoracic echocardiogram is the initial diagnostic modality in the evaluation of AHCM and shows hypertrophy of the LV apex. Other diagnostic modalities, including left ventriculography, multislice spiral computed tomography, and cardiac magnetic resonance imagings, are also valuable tools. Medications used to manage include verapamil, beta-blockers, and antiarrhythmic agents. An implantable cardioverter defibrillator (ICD) is recommended for high-risk patients.

[Endomyocardial fibrosis in Cameroon: Echocardiographic and clinical description of a pediatric series in Yaoundé]

BACKGROUND

Endomyocardial fibrosis is a restrictive cardiomyopathy that causes heart failure. It is characterized by the fibrotic thickening of the endocardium, sometimes involving the myocardium as well. The lesion generally lies at the apices or inflow tracts of one or both ventricles, associated with more or less severe alteration of the valves. It is a disease of the intertropical regions but is not well known in Cameroon. In this study we describe the first series seen in a pediatric hospital in Cameroon.

PATIENTS AND METHODS

A retrospective study was conducted in a pediatric hospital in Yaoundé involving children who had been diagnosed with endomyocardial fibrosis after echocardiographic investigation. We collected the clinical and paraclinical data from consultation records and medical files.

RESULTS

Between January 2006 to December 2013, we registered 1430 patients with a cardiac anomaly in our center. Endomyocardial fibrosis was found in 46 patients. Neither sex predominated. Ages at the time of diagnosis varied between 2 and 17 years. Most of the patients were between 5 and 15 years old (80.4 %), with a median of 10 years (interquartile range, 7-13 years). The main complaints were breathlessness, cough, abdominal distension, abdominal, and loss of appetite. Apart from the hyperpigmentation of the lips observed in all our patients, dyspnea was the most frequent physical sign and the diagnosis was made at a time when signs of heart failure were preponderant. Growth retardation was found in all the children examined. All patients were underweight with a median weight for age found below the 25th percentile of the norms according to the National Health Statistics. Lower limb edema was absent even in the presence of voluminous ascites. All subjects had hyperpigmented lips. Despite the cyanotic appearance of the lips, pulse oximetry always gave a normal oxygen saturation level and no cyanosis was seen elsewhere. None of the patients had nail clubbing. Fibrosis more often affected the right ventricle (45/46 patients). The apical obliteration by fibrotic material was found in 43 (93.5 %) patients. Moreover, 36 (78.3 %) patients had pericardial effusion: mild to moderate in 32 subjects and abundant in four subjects. Hypereosinophilia was noted in 57.5 % of the patients. Atrial fibrillation was found in six out of 15 patients who had an electrocardiogram done.

CONCLUSION

The modes of clinical presentation of endomyocardial fibrosis are not sufficiently well known in our context. Despite its insidious progression, certain signs such as weight loss and hyperpigmented lips could be very helpful for screening and easing orientation of parents and heath personnel, thus enabling early referral for appropriate investigation. The presence of bulky ascites without edema of the lower extremities should be viewed as strongly suggestive.

Endomyocardial fibrosis in Sub Saharan Africa: The geographical origin, socioeconomic status, and dietary habits of cases reported in Yaounde, Cameroon

Background:

Endomyocardial fibrosis (EMF) is a neglected heart condition of the inter-tropical regions. Numerous hypotheses suggest a relationship between its geographical distribution in the affected regions and other etio-pathogenic factors such as dietary habits, infectious causes, and geochemical causes. Knowledge of its epidemiology in Cameroon remains limited, which is why we decided to describe the profile of a paediatric series of EMF in Yaoundé.

Patients and Methods:

A retrospective study was carried out on EMF in 54 patients diagnosed from 1 January 2006-31 December 2014 in a Paediatric Centre of Yaoundé. Diagnosis was mainly echocardiographic. We compiled data on the geographic origins of the patients, their dietary habits and the socioeconomic profile of their families.

Results:

The patients’ ages ranged from 2 to 17 years, most of whom (83.3%) were between 5 and 15 years. For geographical distribution, all came from three tropical forest zones where they have lived since their childhood. These were Center (32/54), South (12/54), and East (10/54). All families had a moderate income, consumed tubers at least twice a week especially cassava (43/54) and had low sources of proteins.

Conclusion:

Apart from geographical similarities all patients of our series shared the same dietary habits. Our study was conducted in a hospital setting; therefore a screening of the disease in the whole national territory would enable a more reliable mapping.

Right ventricular endomyocardial fibrosis (2013 Grover Conference series)

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown origin, affecting predominantly the right side of the heart. Its highest prevalence is in poor regions of sub-Saharan Africa, where it is usually found in children and adolescents. In areas where it is endemic, EMF is a major cause of heart failure and premature death. EMF of the right ventricle has unique clinical, electrocardiographic, and echocardiographic signs. Several features of advanced disease are not fully understood, the most striking being the presence of severe ascites with little or no pedal edema. Echocardiography is the main diagnostic tool and supports management of the disease in most patients, as it allows assessment of the severity and extension of endocardial fibrosis, the quality of the right atrioventricular valve, and the presence of intracardiac thrombi. Pulmonary hypertension in the setting of right EMF is related to chronic thromboembolism, through the chronic thrombi present in the severely enlarged right atrium found in advanced disease. The management of right EMF is difficult. Treatment of symptomatic patients should be surgical. However, as the disease is usually detected in late stages, with severe and advanced lesions, surgery cannot be performed without a very high risk of death and complications. New surgical approaches addressing several components of the structural cardiac abnormalities have been attempted, with promising results. EMF remains one of the most neglected diseases worldwide, and research into its pathophysiological mechanisms will probably improve outcomes and alter the natural history of the disease. This requires improvement in the health systems in areas of endemicity as well as the design of international collaborative research projects.

Forme fruste of isolated right ventricular endomyocardial fibrosis: a case report

Introduction

Endomyocardial fibrosis is a neglected tropical disease of unknown etiology and poor prognosis. It is endemic of tropical climates where it is the most common cause of restrictive cardiomyopathy in the second and fourth decades of life. A forme fruste of the disease is thought to be present in temperate climates where the diagnosis remains exceedingly rare.

Case presentation

We describe a case of isolated right ventricular endomyocardial fibrosis in a 27-year-old Caucasian man from a temperate climate who presented initially with frank hemoptysis and pulmonary thromboembolic disease. We further describe the approach utilized in the diagnosis, the surgical treatment and the outcome of the disease.

Conclusions

We conclude that endomyocardial fibrosis should be included in the differential diagnosis of apical cardiomyopathies in patients from temperate climates.

Recent advances in the epidemiology, diagnosis and treatment of endomyocardial fibrosis in Africa

Endomyocardial fibrosis (EMF) continues to be an important and disabling disease in many parts of Africa, although its prevalence has declined in some parts of the continent. Increased access to medical care in general and increased availability of echocardiography in some parts of the continent have led to recognition of the disease in areas in which the disease had not been previously reported, and this has given new insights into its natural history. However, the early manifestations of EMF continue to elude clinicians and researchers, and no progress has been made in defining its aetiology. Advances have, however, been made in establishing the epidemiology and improving clinical diagnosis and management, through modern medical therapy and improved surgical techniques. Research is still required to define clinical, biological and echocardiographic markers of early stages of EMF, so that advances in the knowledge of its pathogenesis and pathophysiology can be made. This will hopefully determine preventive measures and avoid the burden of this debilitating condition in this continent.

Imaging of scleroderma

Systemic sclerosis is a rare autoimmune condition that affects a variety of organ systems. Knowledge of the imaging features in this patient population is essential in facilitating accurate diagnosis and guiding treatment. Common and rare imaging features of systemic sclerosis are reviewed in this article. Skin, musculoskeletal, pulmonary, cardiac, gastrointestinal, renal, and oral imaging are discussed. Conventional radiography, computed tomography of the chest, echocardiography, enterography, scintigraphy, and panorex dental imaging are reviewed. In addition, the evolving applications of ultrasonography and magnetic resonance imaging to evaluate the musculoskeletal and cardiac features of systemic sclerosis are discussed.

Right ventricular endomyocardial fibrosis - A case report

Endomyocardial fibrosis (EMF) is a progressive type of restrictive cardiomyopathy. It affects inflow portion of right and/or left ventricle and apex. It is a neglected tropical disease. Here we report a rare case of right ventricular endomyocardial fibrosis. A 70-year-old female presented to us with history suggestive of right-sided heart failure of two months duration. There was no eosinophilia. Chest X-ray showed cardiomegaly. Echocardiogram showed dilated right atrium and obliteration of the apex of the right ventricle. A diagnosis of Right ventricular Endomyocardial fibrosis was made. She was treated with diuretics and anticoagulants and she improved.

The changing pattern of endomyocardial fibrosis in South-west Nigeria

Background:

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy, the prevalence of which is declining globally. This study was carried out to determine if there were changing patterns in its local prevalence in South-West Nigeria.

Methods:

We reviewed the medical records of all patients admitted to or attending the cardiology clinic or medical outpatient/specialty clinics in the Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, South-West Nigeria. Medical data for those with EMF from January 2003 to December 2009 were retrieved and analyzed.

Results:

Only three cases of EMF were identified from a total of 12,794 medical patients containing a subset of 7956 cardiac patients. The prevalence of EMF was 0.02% and 0.04% for medical and cardiac patients, respectively. All the patients with EMF were in the second or third decades of life, and had right ventricular EMF and atrial fibrillation, but no eosinophilia.

Conclusion:

This study shows that the prevalence of EMF has declined in the study area from 10% in the 1960s and 1970s to 0.02% for medical cases and 0.04% for cardiac cases in the first decade of the 21st century. Right ventricular EMF still predominates, but without eosinophilia. Improved health care delivery’s positive impact on the control of communicable diseases might be responsible for these observed changes. More work needs to be done both within and outside Nigeria to follow this trend and unravel the mystery surrounding this poorly understood cardiac disease.

Endomyocardial fibrosis causing stroke in a young man

An Indian man in his late 30s presented with ischaemic stroke and eosinophilia of 711/mm(3). ECG showed first-degree heart block with ST depression and symmetrical T-wave inversions in the chest leads. Subsequently, the patient was further evaluated by echocardiography and cardiac MRI which identified the presence of endomyocardial fibrosis in the heart.

Endomyocardial fibrosis: A form of endemic restrictive cardiomyopathy

Endomyocardial fibrosis is a form of endemic restrictive cardiomyopathy that affects mainly children and adolescents, and is geographically restricted to some poor areas of Africa, Latin America and Asia. It is a condition with high morbidity and mortality, for which no effective therapy is available. Although several hypotheses have been proposed as triggers or causal factors for the disease, none are able to explain the occurrence of the disease worldwide. In endemic areas of Africa endomyocardial fibrosis is as common a cause of heart failure as rheumatic heart disease, accounting for up to 20% of cases of heart failure and imposes a considerable burden to the communities and the health systems. However, due to lack of resources for research in these areas, the exact epidemiology, etiology and pathogenesis remain unknown, and the natural history is incompletely understood. We here review the main aspects of epidemiology, natural history, clinical picture and management of endomyocardial fibrosis, proposing new ways to increase research into this challenging and neglected cardiovascular disease.

Heart failure with normal left ventricular ejection fraction: role of echocardiography

PURPOSE OF REVIEW

Nearly half of patients presenting with heart failure have a preserved left ventricular ejection fraction (LVEF), previously known as diastolic heart failure. The diagnosis requires fulfillment of three criteria: signs or symptoms of heart failure, presence of a normal LVEF, and evidence of diastolic dysfunction. Two of the criteria can be evaluated by echocardiography. This article reviews the echocardiographic approach to the patient with suspected heart failure with a normal left ventricular ejection fraction (HFNEF).

RECENT FINDINGS

Echocardiography is the primary modality for evaluating left ventricular (LV) systolic and diastolic function in heart failure patients. Measurements of LVEF from two-dimensional echocardiography can have significant variability despite the use of quantitative methods. The use of contrast agents and three-dimensional echocardiography can improve the accuracy. Newer modalities of tissue Doppler imaging and deformation imaging are challenging the concept that systolic function is preserved in HFNEF. Evaluation of diastolic function with echocardiography requires a comprehensive approach using multiple modalities to quantitate transmitral flow, pulmonary venous flow, mitral annular motion, myocardial deformation, and cardiac structure. The clinical applicability of parameters used for evaluating diastolic function and filling pressures is dependent on the LVEF, necessitating a unique approach in patients with suspected HFNEF.

SUMMARY

A comprehensive examination with knowledge of the potential limitations of echocardiography is required to accurately interpret LV systolic and diastolic function in patients with suspected HFNEF.

Apical hypertrophic cardiomyopathy

We describe a patient with asymptomatic apical hypertrophic cardiomyopathy (AHCM) who later developed cardiac arrhythmias, and briefly discuss the diagnostic modalities, differential diagnosis and treatment option for this condition. AHCM is a rare form of hypertrophic cardiomyopathy which classically involves the apex of the left ventricle. AHCM can be an incidental finding, or patients may present with chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation and congestive heart failure. AHCM is frequently sporadic, but autosomal dominant inheritance has been reported in few families. The most frequent and classic electrocardiogram findings are giant negative T-waves in the precordial leads which are found in the majority of the patients followed by left ventricular (LV) hypertrophy. A transthoracic echocardiogram is the initial diagnostic tool in the evaluation of AHCM and shows hypertrophy of the LV apex. AHCM may mimic other conditions such as LV apical cardiac tumors, LV apical thrombus, isolated ventricular non-compaction, endomyocardial fibrosis and coronary artery disease. Other modalities, including left ventriculography, multislice spiral computed tomography, and cardiac magnetic resonance imagings are also valuable tools and are frequently used to differentiate AHCH from other conditions. Medications used to treat symptomatic patients with AHCM include verapamil, beta-blockers and antiarrhythmic agents such as amiodarone and procainamide. An implantable cardioverter defibrillator is recommended for high risk patients.

Endomyocardial fibrosis: an under-diagnosed cause of cardiomyopathy in Sudanese children

Endomyocardial fibrosis (EMF) is a tropical cardiomyopathy reported in many tropical countries. Patients were seen at the Children's Hospital-Khartoum, Sudan during September 2007-08 where cardiac evaluation was done. Six patients were identified (18% of all children with cardiomyopathy); all were males aged 8-17 years. All patients presented with abdominal distention, stunted growth, raised jugular venous pressure, ascites and hepatosplenomegaly. Electrocardiogram abnormalities included atrial fibrillation, first and third degree AV block and tall P wave. Echocardiography revealed huge right atrium dilatation and right ventricle apex obliteration by fibrous tissue. One patient had left-side affection with moderate mitral regurgitation. Eosinophilia was present in three patients. Two patients received antituberculosis drugs with no improvement, two had history of treated bilharziasis and two had been labeled as having Ebstein disease. EMF is an important cause of cardiomyopathy in Sudan that is often misdiagnosed. Clinical and echocardiographic examinations can lead to the correct diagnosis.

Endomyocardial fibrosis: an enigmatic cause for a giant left atrium

Endomyocardial fibrosis (EMF) was first described in 1948. It is an idiopathic disorder, characterized by the formation of fibrous tissue on the endocardial aspect of one or both ventricles, resulting in a restrictive cardiomyopathy with atrial enlargement. Originally described in Uganda, numerous cases have also been described in the Middle East.

A population study of endomyocardial fibrosis in a rural area of Mozambique

BACKGROUND

Endomyocardial fibrosis is the most common restrictive cardiomyopathy worldwide. It has no specific treatment and carries a poor prognosis, since most patients present with advanced heart failure. On the basis of clinical series, regional variations in distribution have been reported within several countries in Africa, Asia, and South America, but large-scale data are lacking on the epidemiologic features and early stages of the disease.

METHODS

We used transthoracic echocardiography to determine the prevalence of endomyocardial fibrosis in a rural area of Mozambique. We screened a random sample of 1063 subjects of all age groups selected by clustering. Major and minor diagnostic criteria were defined, and a severity score was developed and applied. Cases were classified according to the distribution and severity of the lesions in the heart.

RESULTS

The estimated overall prevalence of endomyocardial fibrosis was 19.8%, or 211 of 1063 subjects (95% confidence interval [CI], 17.4 to 22.2). The prevalence was highest among persons 10 to 19 years of age (28.1%, or 73 of 260 subjects [95% CI, 22.6 to 33.6]) and was higher among male than among female subjects (23.0% vs. 17.5%, P=0.03). The most common form was biventricular endomyocardial fibrosis (a prevalence of 55.5%, or 117 of 211 subjects [95% CI, 48.8 to 62.2]), followed by right-sided endomyocardial fibrosis (a prevalence of 28.0%, or 59 of 211 subjects [95% CI, 21.9 to 34.1]). Most affected subjects had mild-to-moderate structural and functional echocardiographic abnormalities. Only 48 persons with endomyocardial fibrosis (22.7%) were symptomatic. The frequency of familial occurrence was high.

CONCLUSIONS

Endomyocardial fibrosis is common in a rural area of Mozambique. By using echocardiography, we were able to detect early, asymptomatic stages of the disease. These findings may aid in the study of the pathogenesis of the disease and in the development of new management strategies.

Endomyocardial fibrosis: still a mystery after 60 years

The pathologist Jack N. P. Davies identified endomyocardial fibrosis in Uganda in 1947. Since that time, reports of this restrictive cardiomyopathy have come from other parts of tropical Africa, South Asia, and South America. In Kampala, the disease accounts for 20% of heart disease patients referred for echocardiography. We conducted a systematic review of research on the epidemiology and etiology of endomyocardial fibrosis. We relied primarily on articles in the MEDLINE database with either “endomyocardial fibrosis” or “endomyocardial sclerosis” in the title. The volume of publications on endomyocardial fibrosis has declined since the 1980s. Despite several hypotheses regarding cause, no account of the etiology of this disease has yet fully explained its unique geographical distribution.

MRI of hypertrophic cardiomyopathy: part 2, Differential diagnosis, risk stratification, and posttreatment MRI appearances

OBJECTIVE

We present a two-part review about the use of MRI in patients with hypertrophic cardiomyopathy (HCM). This article, Part 2, covers the differential diagnosis, risk stratification, and posttreatment MRI follow-up appearances in these patients.

CONCLUSION

Cardiovascular MRI is a useful imaging tool for the diagnosis of HCM and follow-up of patients after either surgical myomectomy or septal ablation therapy. In addition, MRI can help to discriminate HCM from the differential diagnoses of other cardiomyopathies and cardiac disorders, and it can potentially identify the subset of patients at risk of sudden cardiac death.