How to recognize endomyocardial fibrosis?

Structural heart disease in the tropics: A comprehensive review

Structural heart disease (SHD) remains a significant global health challenge, disproportionately impacting populations in tropical regions where the burden of infectious diseases, limited healthcare infrastructure, and socio-economic disparities exacerbate the issue. The tropics are uniquely affected by conditions such as rheumatic heart disease (RHD), endomyocardial fibrosis, tropical cardiomyopathies, and pericardial diseases, often resulting from or complicated by endemic infections like malaria, dengue, tuberculosis, and parasitic diseases. Moreover, Human Immunodeficiency Virus-Associated Cardiac Disease (HIVAC) represents an emerging concern in regions with high HIV prevalence, adding complexity to the interplay between infectious and structural cardiac conditions. Despite the significant morbidity and mortality associated with SHD in these areas, research and clinical focus have often been inadequate, underscoring the need for a comprehensive synthesis of available evidence to guide future efforts. This review aims to provide a detailed examination of SHD in the tropics, with a focus on valvular, myocardial, and pericardial diseases linked to tropical infections and conditions. It highlights the epidemiology, pathophysiology, and clinical presentation of key diseases, including RHD, endocarditis, Chagas disease, and HIVAC, as well as other less commonly recognized tropical cardiomyopathies and pericardial disorders. The review also explores diagnostic challenges, advances in imaging and molecular tools, and the role of public health interventions and policy in addressing these conditions. By synthesizing current knowledge and identifying gaps, this review aims to inform research priorities, improve clinical care, and support the development of tailored prevention and management strategies for SHD in resource-constrained tropical settings.

Detection of a rare cause of pulmonary hypertension by multimodality imaging: Left ventricular endomyocardial fibrosis

Endomyocardial fibrosis (EMF), a restrictive cardiomyopathy characterized by subendocardial fibrosis, is commonly seen in tropical and subtropical regions. EMF involving the left ventricle presents with severe pulmonary hypertension (PH) and is a rare cause of PH in non-tropical areas. Multimodality imaging is important for accurate diagnosis, especially cardiac magnetic resonance imaging which is the cornerstone. Herein, we report the case of a patient who presented with heart failure symptoms and severe PH, and in whom EMF was diagnosed by multimodality imaging.

Apical hypertrophic cardiomyopathy with subendocardial late gadolinium enhancement in an adolescent

A 17-year-old boy with a history of dyspnea attacks and chest pain was referred to our paediatric cardiology department. Electrocardiogram at presentation showed T-wave inversion in the inferior leads. Cardiovascular magnetic resonance imaging revealed the rare diagnosis of apical hypertrophic cardiomyopathy with subendocardial late gadolinium enhancement, missed by echocardiography.

Tropical Endomyocardial Fibrosis

Tropical endomyocardial fibrosis is a common cause of restrictive cardiomyopathy worldwide, but is relatively rare in developed countries. We present a case of tropical endomyocardial fibrosis with right ventricular involvement initially mistaken as Ebstein’s anomaly. We highlight the need for timely and accurate diagnosis to ensure appropriate management. (Level of Difficulty: Intermediate.)

Genetics of inherited cardiomyopathies in Africa

In sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCDs) is rising disproportionately in comparison to the rest of the world, affecting urban, semi-urban and rural dwellers alike. NCDs are predicted to surpass infections like human immunodeficiency virus, tuberculosis and malaria as the leading cause of mortality in SSA over the next decade. Heart failure (HF) is the dominant form of cardiovascular disease (CVD), and a leading cause of NCD in SSA. The main causes of HF in SSA are hypertension, cardiomyopathies, rheumatic heart disease, pericardial disease, and to a lesser extent, coronary heart disease. Of these, the cardiomyopathies deserve greater attention because of the relatively poor understanding of mechanisms of disease, poor outcomes and the disproportionate impact they have on young, economically active individuals. Morphofunctionally, cardiomyopathies are classified as dilated, hypertrophic, restrictive and arrhythmogenic; regardless of classification, at least half of these are inherited forms of CVD. In this review, we summarise all studies that have investigated the incidence of cardiomyopathy across Africa, with a focus on the inherited cardiomyopathies. We also review data on the molecular genetic underpinnings of cardiomyopathy in Africa, where there is a striking lack of studies reporting on the genetics of cardiomyopathy. We highlight the impact that genetic testing, through candidate gene screening, association studies and next generation sequencing technologies such as whole exome sequencing and targeted resequencing has had on the understanding of cardiomyopathy in Africa. Finally, we emphasise the need for future studies to fill large gaps in our knowledge in relation to the genetics of inherited cardiomyopathies in Africa.

Characterization of Cardiopulmonary Exercise Testing Variables in Patients with Endomyocardial Fibrosis after Endocardial Resection

BACKGROUND

Endomyocardial fibrosis (EMF) is a rare disease, characterized by diastolic dysfunction which leads to reduced peak oxygen consumption (VO2). Cardiopulmonary exercise testing (CPET) has been proved to be a fundamental tool to identify central and peripheral alterations. However, most studies prioritize peak VO2 as the main variable, leaving aside other important CPET variables that can specify the severity of the disease and guide the clinical treatment.

OBJECTIVE

The aim of this study was to evaluate central and peripheral limitations in symptomatic patients with EMF by different CPET variables.

METHODS

Twenty-six EMF patients (functional class III, NYHA) were compared with 15 healthy subjects (HS). Functional capacity was evaluated using CPET and diastolic and systolic functions were evaluated by echocardiography.

RESULTS

Age and gender were similar between EMF patients and HS. Left ventricular ejection fraction was normal in EMF patients, but decreased compared to HS. Peak heart rate, peak workload, peak VO2, peak oxygen (O2) pulse and peak pulmonary ventilation (VE) were decreased in EMF compared to HS. Also, EMF patients showed increased Δ heart rate /Δ oxygen uptake and Δ oxygen uptake /Δ work rate compared to HS.

CONCLUSION

Determination of the aerobic capacity by noninvasive respiratory gas exchange during incremental exercise provides additional information about the exercise tolerance in patients with EMF. The analysis of different CPET variables is necessary to help us understand more about the central and peripheral alterations cause by both diastolic dysfunction and restrictive pattern.

Multimodality Imaging in Restrictive Cardiomyopathies: An EACVI expert consensus document In collaboration with the "Working Group on myocardial and pericardial diseases" of the European Society of Cardiology Endorsed by The Indian Academy of Echocardiography

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.