Diagnostic pathways leading to arrhythmogenic left ventricular cardiomyopathy in a single center cohort

Background

Despite major advances, the recognition of arrhythmogenic left ventricular cardiomyopathy (ALVC) remains challenging, since this clinical entity is often concealed in different clinical settings both in terms of clinical onset and imaging phenotype, resulting in significant delays in diagnosis with prognostic implications.

Purpose

To describe a single Center cohort of ALVC patients, focusing on the spectrum of clinical presentation and diagnostic pathways.

Methods

Patients were retrospectively evaluated between January 2012 and January 2022. Diagnosis was based on 1) ≥3 contiguous segments with subepicardial/midwall LGE in the LV at cardiac magnetic resonance (CMR) plus a likely pathogenic/pathogenic arrhythmogenic cardiomyopathy (ACM) associated genetic mutation and/or familial history of ACM and/or red flags for ALVC (i.e, negative T waves in V4–6/aVL, low voltages in limb leads) or 2) pathology examination of explanted hearts/autoptic cases suffering from sudden cardiac death (SCD). Patients with significant right ventricular involvement were excluded.

Results

Sixty-six patients were evaluated for suspected ALVC: 8 phenocopies were excluded (6 acute myocarditis and 2 sarcoidosis) after a comprehensive clinical and multi-modality instrumental evaluation. The final study cohort was composed by 56 patients (55% males, median age 45 years), from 36 families. Diagnostic pathways leading to diagnosis were: SCD in 4 (7%), ventricular arrhythmias in 11 (20%), chest pain in 9 (16%), heart failure in 7 (12%), and familial screening in 25 (45%) (Figure 1). An echocardiogram was available for all but 2 patients with SCD: 25 (46%) had normal phenotype, 17 (32%) had a hypokinetic non dilated cardiomyopathy, and 12 (22%) had a dilated cardiomyopathy (DCM). Of the 49 tested patients, 31 (63%) had a pathogenic/likely pathogenic DNA variant: desmoplakin (DSP, N=21), filamin C (FLNC, N=4), SCN5A (N=3) were the most frequently involved genes; 8 patients had a double gene mutation. Twenty-four patients (43%) had previously received a diagnosis other than ALVC: 10 idiopathic DCM, 9 acute myocarditis, 4 post-myocarditis DCM, 2 acute myocardial injury/non-ST elevated myocardial infarction. In 13 patients ALVC was diagnosed with the introduction of CMR in the diagnostic work-up of a DCM, in 2 cases the diagnosis was done with the pathology examination after heart transplantation. The median diagnostic delay was of 8 years, with a maximum of 20 years. It is worth nothing that patients from the same family might have different diagnostic pathways and phenotypes of ALVC (Figure 2).

Conclusions

ALVC is a challenging diagnosis, hidden in different clinical scenarios. Five main clinical pathways leading to ALVC diagnosis may be identified: ventricular arrhythmias, chest pain, heart failure, SCD at first presentation, and clinical/instrumental familial screening.

Funding Acknowledgement

Type of funding sources: None.

An Italian multicentre distributed data research network to study the use, effectiveness, and safety of immunosuppressive drugs in transplant patients: Framework and perspectives of the CESIT project

The goal of post-transplant immunosuppressive drug therapy is to prevent organ rejection while minimizing drug toxicities. In clinical practice, a multidrug approach is commonly used and involves drugs with different mechanisms of action, including calcineurin inhibitors (CNI) (tacrolimus or cyclosporine), antimetabolite (antimet) (mycophenolate or azathioprine), inhibitors of mechanistic target of rapamycin (mTOR) (sirolimus or everolimus), and/or steroids. Although evidence based on several randomized clinical trials is available, the optimal immunosuppressive therapy has not been established and may vary among organ transplant settings. To improve the knowledge on this topic, a multiregional research network to Compare the Effectiveness and Safety of Immunosuppressive drugs in Transplant patients (CESIT) has been created with the financial support of the Italian Medicines Agency. In this article, we describe the development of this network, the framework that was designed to perform observational studies, and we also give an overview of the preliminary results that we have obtained. A multi-database transplant cohort was enrolled using a common data model based on healthcare claims data of four Italian regions (Lombardy, Veneto, Lazio, and Sardinia). Analytical datasets were created using an open-source tool for distributed analysis. To link the National Transplant Information System to the regional transplant cohorts, a semi-deterministic record linkage procedure was performed. Overall, 6,914 transplant patients from 2009–19 were identified: 4,029 (58.3%) for kidney, 2,219 (32.1%) for liver, 434 (6.3%) for heart, and 215 (3.1%) for lung. As expected, demographic and clinical characteristics showed considerable variability among organ settings. Although the triple therapy in terms of CNI + antimet/mTOR + steroids was widely dispensed for all settings (63.7% for kidney, 33.5% for liver, 53.3% for heart, and 63.7% for lung), differences in the active agents involved were detected. The CESIT network represents a great opportunity to study several aspects related to the use, safety, and effectiveness of post-transplant maintenance immunosuppressive therapy in real practice.

Clinical importance of left atrial infiltration in cardiac transthyretin amyloidosis

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

 The clinical significance of left atrial (LA) involvement in ATTR amyloidosis cardiomyopathy (ATTR-CM) has not been characterized. The aims of this study were to characterize: (1)LA pathology in explanted ATTR-CM hearts; (2)LA mechanics using echocardiographic speckle-tracking in a large cohort of ATTR-CM patients; (3)to study the association with mortality.

METHODS AND RESULTS

Congo red staining and immunohistochemistry was performed to assess the presence, type and extent of amyloid and associated changes in 5 explanted ATTR-CM atria. Echo speckle-tracking was used to assess LA reservoir, conduit, contractile function and stiffness in 906 ATTR-CM patients (551 wt-ATTR-CM;93 T60A-ATTR-CM;241 V122I-ATTR-CM;21 other).

There was extensive ATTR amyloid infiltration in the 5 atria with loss of normal architecture, vessels remodelling, capillary disruption and subendocardial fibrosis. Echo speckle-tracking in 906 ATTR-CM patients demonstrated increased atrial stiffness [median(25th-75th quartile) 1.83(1.15-2.92)] that remained independently associated with prognosis, after adjusting for known predictors (lnLA stiff:HR = 1.26,CI 1.07-1.57;p = 0.009). There was substantial impairment of the three phasic functional atrial components [reservoir 8.86(5.94-12.97)%; conduit 6.5(4.53-9.28)%; contraction function 4.0(2.29-6.56)%]. Atrial contraction was absent in 21.6% of patients whose ECG showed sinus rhythm (SR)-"atrial electro-mechanical dissociation"(AEMD). AEMD was associated with poorer prognosis compared to SR patients with effective mechanical contraction (p < 0.0001). AEMD conferred a similar prognosis to patients in AF.

CONCLUSION

The phenotype of ATTR-CM includes significant infiltration of the atrial walls with progressive loss of atrial function and increased stiffness, which is a strong independent predictor of mortality. AEMD emerged as a distinctive phenotype identifying patients in SR with poor prognosis.

Abstract Figure.

Diagnostic accuracy of cardiac computed tomography and 18F-fluorodeoxyglucose with positron emission tomography/computed tomography in cardiac masses

Background

Understanding the nature of cardiac masses represents a challenge for clinicians in order to select the appropriate therapeutic strategies. The diagnostic accuracy of cardiac computed tomography (CT) and 18F-fluorodeoxyglucose (18F-FDG) with positron emission tomography/CT (PET/CT) in identifying the nature of cardiac masses has not been evaluated before in a large population.

Purpose

To assess the diagnostic value of CT and 18F-FDG PET/CT in defining the nature of cardiac masses, integrating morphologic features and metabolic activity.

Methods

Out of 223 we selected a final cohort 60 patients which underwent cardiac CT scan and 18F-FDG PET/CT. All masses had histological certain, apart from thrombi, in which was defined radiologic resolution after adequate anticoagulant treatment. For each mass, eight morphologic CT signs and standardized uptake value (SUVmax, SUVmean), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) in 18F-FDG PET, were evaluated.

Results

Twenty patients had benign cardiac masses and 40 patients malignant cardiac masses. Irregular tumour margins, pericardial effusion, invasions, solid nature of the mass, mass diameter, TC contrast up-take and pre-contrast characteristics were strongly associated with the malignant nature of cardiac masses (p<0.001). Additionally, the presence of at least four CT signs was able to discriminate malignancies, withsensitivity of 95% and specificity of 95% (AUC=0.988, 95% CI 0.969–1). The mean value of SUVmax, SUVmean, MTV and TLG was significantly higher in malignant cardiac masses than in benign lesions (p<0.001). ROC curve for diagnostic accuracy of 18F-FDG PET/CT parameters in detecting malignant lesions showed an excellent performance of SUV (AUC=0.948, 95% CI 0.891–1), MTV (AUC=0.928, 95% CI 0.841–1) and TLG (AUC=0.961, 95% CI 0.902–1).

Conclusions

In patients with cardiac masses, cardiac computed tomography and 18F-FDG PET/CT findings provide independent and incremental prognostic information regarding their nature. A systematic use of CT and 18F-FDG PET/CT is therefore useful for diagnostic and therapeutic purposes.

PET-CT evaluation of cardiac masses

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): S. Orsola Malpighi Hospital, University of Bologna

Colonic Perforation as Initial Presentation of Amyloid Disease: Case Report and Literature Review

INTRODUCTION

Amyloidosis is an uncommon disease caused by the deposition of amyloid fibrils in tissues. This disease does not usually require surgical intervention, which could be warranted in the presence of complications such as bleeding, obstruction, or perforation. We present a case of primary amyloidosis of the colon in a patient affected by polymyositis who underwent Hartmann's procedure after a spontaneous colonic perforation. After 2 months of well-being, the patient underwent two consecutive surgical procedures for stenosis of the ostomy orifice.

AREAS COVERED

A review of the literature has been performed, gathering case reports highlighting the distribution of this disease by age, gender, location, and treatment when available.

EXPERT COMMENTARY

Gastrointestinal amyloid disease is a rare condition, and it could be considered among the rare causes of intestinal perforation. Timely surgical management is often necessary.

P663 Is echocardiogram alone sufficient for cardiac masses characterization?

BACKGROUND

Cardiac Masses (CM) represent an heterogeneous group with a prevalence of 0.3% at autopsy, divided in benign masses (primary tumors and pseudotumors) and malignant ones (primitive tumors and metastasis). 2-D Echocardiography is nowadays the first line approach to define nature and management of CM, but is it enough to guide a therapeutic strategy?

PURPOSE

To evaluate echocardiographic diagnosis accuracy for CM in patients admitted to our Centre between 1997 and 2017.

MATERIALS AND METHODS

We retrospectively evaluated a population of 180 consecutive patients (45% males; mean age 60 ± 16 years; BMI 25 ± 5 Kg/m2), referred to our echocardiographic lab with suspicion CM. All patients were examined in both left lateral and supine position, and heart was visualized from all available echocardiographic windows. Definite diagnosis was obtained by histologic examination of biopsy, surgical samples or, in cases of cardiac thrombi, by radiological evidence of thrombus resolution after adequate anticoagulant treatment. We excluded normal anatomical variants in the group of pseudotumors due to the impossibility of obtaining histological examination. Sensitivity, specificity, predictive accuracy for a positive test, and predictive accuracy for a negative test were calculated by standard formulas (corrected for prevalence by Bayes theorem).

RESULTS

We detected 129 benign CM and 51 malignant cardiac tumors. In 7 cases a poor acoustic window did not allow an optimal examination; in remaining 173 patients, the classical 2-D echocardiogram identified 157 masses with a diagnostic accuracy of 91%. Of 173 CM diagnosed, 146 were classified by echocardiographer as benign masses (125 true benign on histological examination) and 27 as malignant ones (all malignant after histological confirmation); the results showed 56% sensitivity, 100% specificity, 100% positive predictive value, 98% negative predictive value, with 88% overall diagnostic accuracy in identifying the nature of masses. 23 cases were undetermined and needed second level instrumental investigations to be characterized. Diagnostic accuracy for distinguishing primary benign tumors and pseudotumors decreased to 80%, with a significant increase in both "false" benign tumors (9 out of 91) and "false" pseudotumors (15 out of 34) with 85% sensitivity, 68% specificity, 10% positive predictive value, 99% negative predictive value.

CONCLUSION

2D Echocardiography is an excellent, non invasive technique for first line evaluation of patients with suspicion CM. It is safe, reliable with a high predictive value and diagnostic accuracy in identifying CM and their benign or malignant nature. In contrast, these results were insufficient to start an anticoagulant in suspicion thrombus or cardiac surgery for primary tumor, since second level instrumental examinations needed. 2D Echocardiography alone seems unuseful for classifying malignant masses in primitive or metastasis.

P6455Differences in cardiac phenotype and natural history of laminopathies with and without neuromuscular presentation

Aim

To look for differences in cardiac phenotype and natural history of patients affected by laminopathy, according to the presence or less of neuromuscular involvement at clinical presentation.

Methods

We prospectively analyzed 47 consecutive pts with a genetic diagnosis of laminopathy followed at a single centre between 1994 and 2017. Additionally, reports of clinical and instrumental evaluations before referral at our centre were retrospectively evaluated.

Results

Neuromuscular presentation, mainly as Emery-Dreifuss muscular dystrophy (EDMD), was present in 21 (46%) cases (14 LMNA and 7 EMD gene mutations). These pts had symptoms earlier (9 vs 39 years, p<0.001) in life compared to pts without neuromuscular onset (26 LMNA gene mutations), and clinical manifestations anticipated the first evidence of cardiac disease by a mean time of 15±8 years (maximum time gap of 38 years). Despite a similar prevalence of atrial fibrillation/flutter (AF) (71% vs 65%, p=0.758) and atrio-ventricular blocks (48% vs 65%, p=0.250), pts with neuromuscular onset experienced AF and pace-maker implantation at a significantly younger age (27 vs 41 yrs, p=0.015 and 23 vs 44 yrs, p=0.027 respectively). Differently a higher prevalence of sinus node dysfunction (33% vs 4%; p=0.015) and atrial paralysis (14% vs 4%; p=0.311) was reported in pts with neuromuscular onset. Prevalence of cardiomyopathy (CMP) (73% vs 33%, p=0.008) and sustained ventricular tachyarrhythmias were higher among pts with cardiac onset (23% vs 4%, p=0.111) whereas the prevalence of heart transplantations and median age of recipients were similar in the two groups (24% vs 20%, p=1.000 and 46 vs 43, p=0.592 years respectively). All pts with neuromuscular onset who received a diagnosis of CMP had a previous history of rhythm disturbance except 2 cases, where a concomitant diagnosis of the 2 disorders was formulated. On the contrary a strict temporal progression from rhythm disturbances to CMP (or viceversa) was not appreciable in the other group: AF and AVBs could precede the diagnosis of CMP be diagnosed at the same time or later.

Conclusions

In pts affected by laminopathy neuromuscular involvement, when present, was most often the first clinical manifestation and preceded cardiological involvement, with a long time frame in some cases. Except for sinus node dysfunction, much more frequent in patients with EDMD, a similar prevalence of rhythm disturbances was reported, although pts with neuromuscular clinical onset were younger at diagnosis of AF and at PM implantation. Pts without neuromuscular presentation had a higher prevalence of CMP and ventricular arrhythmias, albeit a similar rate of heart transplantation. In pts with neuromuscular onset, cardiac involvement was characterized by a stepwise progression from rhythm disturbances to CMP, where a strict temporal progression from rhythm disturbances to CMP was not observed in the group of pts without neuromuscular clinical onset.

P900Electrocardiographic findings in Anderson-Fabry disease versus sarcomeric hypertrophic cardiomyopathy

Background

Cardiac involvement is one of the most frequent and disabling organ damage in Anderson-Fabry (AF) disease, causing hypertrophic cardiomyopathy (HCM), conduction disturbances, arrhythmias and coronary disease. Differential diagnosis from sarcomeric HCM is often very challenging, especially for patients with exclusive cardiac involvement.

Purpose

To gain new insights from standard electrocardiogram (ECG) in AF disease, and identify ECG differences from sarcomeric HCM.

Methods

Sixty-two consecutive patients (27 males, mean age: 62±16 years) with definite diagnosis of AF disease from 2 Italian centres were evaluated for ECG analysis and divided in 2 groups, according to the presence (Group A, N=39) or the absence (Group B, N=26) of cardiac involvement [hypertrophy detected at echocardiogram or cardiac magnetic resonance (CMR)]. All ECGs were analysed by 2 independent investigators. For Group A, when CMR was performed, a correlation between CMR and ECG was assessed. Patients with cardiac involvement were matched with 78 sarcomeric HCM patients according to sex, age and septal wall thickness on echocardiogram.

Results

Two AF patients out 39 with cardiac involvement (5%) had normal ECG. Short PR and I degree atrio-ventricular (AV) block were both reported in 6 (15%) cases. Twenty-six (67%) patients showed left ventricular hypertrophy and the majority (85%) had abnormal repolarization. CMR was performed in 22 patients (56%); the 11 (50%) patients with replacement fibrosis had a higher mean Sokolow-Lyon score (4.1±1.8 vs 2.9±1.0 mV; p=0.05), more frequent ST segment depression (82 vs 27%; p=0.03) and negative T waves (91 vs 36%; p=0.027; sensitivity: 90%; specificity: 63%), compared with the 11 without replacement fibrosis.

When compared with sarcomeric HCM, AF patients with cardiac involvement had a significantly wider QRS (120±30 vs 100±16 msec; p<0.0001), a higher frequency of right bundle branch block (RBBB) (18 vs 3%; p=0.01), ST segment depression (54 vs 20%; p<0.0001) and negative T waves (72 vs 46%; p=0.01), typically in the inferior leads (44 vs 14%; p<0.0001). No significant differences in terms of pseudo-necrosis and QRS voltages were found.

Among Group B AF patients (26, mean age: 36±12 years), 4 had short PR and 5 incomplete RBBB. Four had an abnormal ECG (1 left atrial enlargement, 2 unspecific repolarization abnormalities, 1 Sokolow score of 3.5 mV).

Conclusions

Standard ECG can detect cardiac involvement in AF disease. A good correlation was reported between repolarization abnormalities and replacement fibrosis on CMR. Wide QRS and RBBB were more frequent among AF patients compared to age-sex-matched sarcomeric HCM ones, probably due to the different aetiology of the diseases (infiltrative disease vs pure hypertrophy).

Inflammatory cell burden and phenotype in endomyocardial biopsies with antibody-mediated rejection (AMR): a multicenter pilot study from the AECVP

This multicenter case-controlled pilot study evaluated myocardial inflammatory burden (IB) and phenotype in endomyocardial biopsies (EMBs) with and without pathologic antibody-mediated rejection (pAMR). Sixty-five EMBs from five European heart transplant centers were centrally reviewed as positive (grade 2, n = 28), suspicious (grade 1, n = 7) or negative (n = 30) for pAMR. Absolute counts of total, intravascular (IV) and extravascular (EV) immunophenotyped mononuclear cells were correlated with pAMR grade, capillary C4d deposition, donor specific antibody (DSA) status and acute cellular rejection (ACR). In pAMR+ biopsies, equivalent number of IV CD3+ T lymphocytes (23 ± 4/0.225 mm(2) ) and CD68+ macrophages (21 ± 4/0.225 mm(2) ) were seen. IB and cell phenotype correlated with pAMR grade, C4d positivity and DSA positivity (p < 0.0001). High numbers of IV T lymphocytes were associated with low grade ACR (p = 0.002). In late-occurring AMR EV plasma cells occurring in 34% of pAMR+ EMBs were associated with higher IB. The IB in AMR correlated with pAMR+, C4d positivity and DSA positivity. In pAMR+ equivalent numbers of IV T lymphocytes and macrophages were found. The presence of plasma cells was associated with a higher IB and occurrence of pAMR late after transplantation.

Criteria for histopathologic diagnosis of aortic disease consensus statement from the SIAPEC-IAP study group of "cardiovascular pathology" in collaboration with the association for Italian cardiovascular pathology

Nowadays, the histopathological study of surgical specimens is an essential part of the diagnostic work-up in aortic disease, and not only in characterizing the neoplastic forms. Despite increasing clinico-therapeutic complexity of aortic pathology, the criteria for histopathological diagnosis have not been properly updated over the years, with the result that we find inconsistent terminology and little standardization of diagnostic criteria. In light of this consideration, the SIAPeC-IAP Study Group of "Cardiovascular Pathology", in collaboration with the Association for Italian Cardiovascular Pathology, has created this consensus document, with the aim of defining the features of histopathological substrates in the main non-neoplastic aortopathies (atherosclerotic, "degenerative"/non inflammatory, and inflammatory) and of systematizing diagnostic criteria even for the rare tumours of the aorta and pulmonary artery. The principal aims of the project are defining histopathological diagnostic criteria, standard nomenclature and classification, methodology and reporting of histopathological study and handling of aortic specimens. In addiction, some current issues and new knowledge emerging from basic aortic research are debated, with the aim of promoting a "modern" and up-to-date view of aortic pathology.

Cognitive functioning and survival in the elderly: the SSADH C538T polymorphism

The variability of the Succinic Semialdehyde Dehydrogenase (SSADH, or ALDH5A1) gene affects both pathological and normal phenotypes correlated to cognitive function. We tested the association between the C538T polymorphism of the SSADH gene and preservation of cognitive function in the elderly, and its possible effects on survival. A sample from southern Italy (514 subjects; 18-107 years) was screened for C538T variability. We found that, within the 65-85 years age range, the T/T genotype is overrepresented in subjects with impaired cognitive function (MMSE < or = 23) compared to those with conserved cognitive function (MMSE > 23). Furthermore, we found that the T/T genotype affects survival after 65 years of age. In fact, after this age, the survival function of T/T homozygous subjects is lower than that of the others. Given that the enzymatic activity of the protein encoded by allele T is 82.5% of the activity of the protein encoded by allele C, our results suggest that the efficiency of the SSADH enzyme is important for the preservation of cognitive function and survival in the elderly.

Long-Term Safety and Effectiveness of Statins for Heart Transplant Recipients in Routine Clinical Practice

BACKGROUND

Whereas the efficacy of statins after heart transplantation (HT) in controlled study settings has been clearly demonstrated, more extensive data are required on the safety and effectiveness of long-term treatment in routine clinical practice.

METHODS

We analyzed the risks and benefits in clinical practice of treatment with statins in all patients who survived HT for at least a month from December 1985 through 2001.

RESULTS

During a mean follow-up of 4.8+/-3.8 years, 186 patients were treated with statins (for a median duration [25th to 75th percentile] of 29 [12 to 54] months), while 48 received dietary therapy alone. Patients treated with statins (pravastatin, 48%; atorvastatin, 37%; simvastatin, 14%) presented linearized rates of rhabdomyolisis, myositis, and significant transaminase elevation of 0.37%, 0.74%, and 0.37% per year of treatment, respectively (no fatal event occurred). Low-density lipoprotein decreased after statins by 19% (P<.001). At multivariate analysis, treatment with statins was independently associated with reduced risk of cardiac allograft vasculopathy and overall mortality (P<.001).

CONCLUSIONS

Our data provide necessary confirmation of the safety and effectiveness in routine clinical practice of appropriately monitored long-term administration of statins (particularly atorvastatin, pravastatin, and simvastatin) in the chronic post-HT phase. Strict follow-up is needed for HT recipients receiving high doses of statins with/without other medications potentially exacerbating the risk of adverse effects.

Wide spectrum of presentation and variable outcomes of isolated left ventricular non-compaction

OBJECTIVES

To investigate diagnostic routes, echocardiographic substrates, outcomes and prognostic factors in patients with isolated ventricular non-compaction (IVNC) identified by echocardiographic laboratories with referral from specialists and primary care physicians.

PATIENTS AND DESIGN

Since 1991, all patients with suspected IVNC were flagged and followed up on dedicated databases. Patients were divided into symptom-based and non-symptom-based diagnostic subgroups.

RESULTS

65 eligible patients were followed up for 6-193 months (mean 46 (SD 44). In 53 (82%) patients, IVNC was associated with variable degrees of left ventricular (LV) dilatation and hypokinesia, and in the remaining 12 (18%) LV volumes were normal. Diagnosis was symptom based in 48 (74%) and non-symptom based in 17 (26%) (familial referral in 10). The non-symptom-based subgroup was characterised by younger age, lower prevalence of ECG abnormalities, better systolic function and lower left atrial size, whereas the extent of non-compaction was not different. No major cardiovascular events occurred in the non-symptom-based group, whereas 15 of 48 (31%) symptomatically diagnosed patients experienced cardiovascular death or heart transplantation (p = 0.01, Kaplan-Meier analysis). Independent predictors of cardiovascular death or heart transplantation were New York Heart Association class III-IV, sustained ventricular arrhythmias and left atrial size.

CONCLUSIONS

IVNC is associated with a broad spectrum of clinical and pathophysiological findings, and the overall natural history and prognosis may be better than previously thought. Adult patients with incidental or familial discovery of IVNC have an encouraging outlook, whereas those who have symptoms of heart failure, a history of sustained ventricular tachycardia or an enlarged left atrium have an unstable course and more severe prognosis.

Non-invasive evaluation of the myocardial substrate of cardiac amyloidosis by gadolinium cardiac magnetic resonance

OBJECTIVE

To investigate the prevalence and distribution of gadolinium (Gd) enhancement at cardiac magnetic resonance (CMR) imaging in patients with cardiac amyloidosis (CA) and to look for associations with clinical, morphological, and functional features.

PATIENTS AND DESIGN

21 patients with definitely diagnosed CA (nine with immunoglobulin light chain amyloidosis and 12 transthyretin related) underwent Gd-CMR.

RESULTS

Gd enhancement was detected in 16 of 21 (76%) patients. Sixty six of 357 (18%) segments were enhanced, more often at the mid ventricular level. Transmural extension of enhancement within each patient significantly correlated with left ventricular (LV) end systolic volume (r = 0.58). The number of enhanced segments correlated with LV end diastolic volume (r = 0.76), end systolic volume (r = 0.6), and left atrial size (r = 0.56). Segments with > 50% extensive transmural enhancement more often were severely hypokinetic or akinetic (p = 0.001). Patients with > 2 enhanced segments had significantly lower 12 lead QRS voltage and Sokolow-Lyon index. No relation was apparent with any other clinical, morphological, functional, or histological characteristics.

CONCLUSION

Gd enhancement is common but not universally present in CA, probably due to expansion of infiltrated interstitium. The segmental and transmural distribution of the enhancement is highly variable, and mid-ventricular regions are more often involved. Enhancement appears to be associated with impaired segmental and global contractility and a larger atrium.

Osteoma of maxillary sinus: case report

Cranio-facial osteomas are frequent in the nasal and paranasal sinuses, particularly in fronto-ethmoidal sites; other sinus cavities are more rarely affected. Although various theories (embryogenetic, traumatic and inflammatory) have been advanced to explain the pathogenesis, it is difficult to establish a specific cause-effect relationship. Nasal and paranasal osteomas are generally asymptomatic and are diagnosed on the basis of X-rays performed for other conditions, the onset of sinusitis-like symptoms or the appearance of complications due to sinus diseases. These cases require surgical removal to avoid the risk of short- or long-term complications or to solve any that may already exist. Herein, a rare case of osteoma of the maxillary sinus is described and the possible aetiopathogenetic role of traumatic and inflammatory factors described. The main clinical and therapeutic data concerning this lesion are examined.

Amyloid deposition as a cause of atrial remodelling in persistent valvular atrial fibrillation

AIM

The spectrum of histological alterations, namely atrial amyloidosis, in the right and left atria of patients with chronic persistent atrial fibrillation (AF) and rheumatic heart disease is not completely known.

METHODS AND RESULTS

One hundred and twenty-eight atrial appendages (66 left and 62 right), obtained from 72 patients with rheumatic valve disease and chronic AF undergoing cardiac surgery for valve replacement or repair and AF treatment were histologically evaluated for the presence of amyloid deposits. One hundred and four specimens of left and right auricles from 52 patients in sinus rhythm with severe chronic heart failure undergoing heart transplant were also analyzed (controls). Amyloid was found in 33 (46%) valvular patients with chronic persistent AF and in 6 (12%) controls. Amyloid was related to the presence and duration of AF, was more frequently found in left atrial samples and was independent of age. On stepwise logistic regression analysis, AF duration and female gender were independently related to amyloid deposition.

CONCLUSIONS

Patients with long-standing AF and rheumatic heart disease have a very high prevalence of atrial amyloidosis. Amyloid deposition is more frequent in left than in right atrial appendage and correlates with AF duration and female gender. Amyloid deposition could constitute an additional histological feature in the structural remodeling of atria during long-standing AF, at least in rheumatic valve disease. Persistence of AF might play a pivotal role in promoting amyloid deposition.

Rhinopharynx endoscopy in the diagnosis of chronic otitis media with effusion in infancy

Chronic otitis media with effusion is an inflammatory process of the mucosa of the middle ear persisting for more than 3 months, being most frequent in infancy, and is correlated with marked tube obstruction. In infancy, the most frequent cause of this obstruction is adenoid hypertrophy and diagnosis, clinical or radiological, is often not confirmed by rhinopharynx fiberendoscopy. Since, in these cases, treatment is often surgical, it is possible that small patients may be submitted, unnecessarily, to adenoidectomy. In collaboration with the Paediatric Clinic, the present study on an infant outpatient population with nasal respiratory difficulty, associated with chronic otitis media with effusion, was, therefore, aimed at standardizing the endoscopic diagnosis of patients with suspected adenoid hypertrophy. Between October and December 2002, 32 consecutive patients, aged between 4 and 11 years, all oral breathers with OME, were sent to our attention from the Paediatric Clinic. All those patients, with indication for adenoidectomy, have been enrolled in the study and submitted to fiberendoscopic examination of the external ear and nose. Nasal respiration was confirmed with active anterior rhinomanometry. Endoscopic evaluation of the rhinopharynx, aimed at assessing adenoid dimensions and their relationship with the auditory tube, has been expressed in four degrees of increasing severity and adenoidectomy was indicated in those cases, classified, by us, as third and fourth degree. In our experience, endoscopic examination of the rhinopharynx has, however, shown that only 9 children (28.2%) presented an absolute need to undergo adenoidectomy since they were carriers of massive adenoid hypertrophy with tubal obstruction and consequent bilateral glue ear (3rd and 4th degree) while, in all other cases (71.8%), the clinical and radiological findings did not correspond to endoscopic data. Diagnostic accuracy that characterizes rhinopharyngeal fiberendoscopy is, therefore, in our opinion, of fundamental importance to avoid these errors, as far as possible, and in establishing an appropriate therapeutic programme.

Fantoni's translaryngeal tracheotomy complications. Personal experience

Tracheotomy is a surgical procedure which, in conditions of acute respiratory emergency, guarantees an adequate airway through the trachea whereas, in cases of chronic respiratory failure, it is used to improve ventilation through the reduction of the dead respiratory space. Over the last few years, surgical techniques used in tracheotomy have been considerably modified, not only to respond to the needs of clinical indications but also on account of problems related to management of the patient and tracheostomy tube, particularly in the home setting. Besides traditional surgical techniques, in fact, in the Intensive Care Unit, percutaneous dilatative procedures are being used with increasing frequency, in particular, translaryngeal tracheotomy according to Fantoni. The latter, however, according to reports in the literature, has been shown to be followed by a higher peri-operative complication rate (40%) which involves maintenance of good function of the tracheostomy, a condition which is particularly dangerous in the management of patients in the home setting. Personal experience is described in the management of 6 patients submitted to tracheotomy according to Fantoni and in combined home treatment, who, some time after the operation. presented 'embedding' of the tracheostomy tube in the tracheostomy opening. The six patients were treated at home with ventilatory support using automatic ventilation system and were submitted, in our Clinic, to a surgical review with preparation of a tracheotomy according to the conventional method. Our experience showed a particular feature of the difficulty in the management of patients presenting respiratory diseases, submitted to translaryngeal tracheotomy and, thereafter, maintained in combined home treatment: in these subjects, in fact, the presence of the tube, the difficulty in cleaning the peristomial skin, the reduced autonomy from the automatic ventilation system and the frequent coexistence of mucopurulent tracheo-bronchial inflammatory diseases, trigger micro-lesions of the stoma and, therefore, scar keloid, narrowing of the lumen and embedding of the tube itself. In conclusion, in our personal experience, we are of the opinion that translaryngeal tracheotomy, since it is easily carried out and is a slightly invasive procedure, plays a very important role in the management of the Intensive Care Unit patient but should be reserved for the few cases requiring tracheostomy for limited periods of time, in low risk patients and within the first 18 days after the acute damaging event.

Folate supplementation after heart transplantation: effects on homocysteine plasma levels and allograft vascular disease

BACKGROUND AND AIMS

After heart transplantation, the effects of folate supplementation on total homocysteine plasma levels (THcy) and heart allograft vascular disease (AVD) remain unclear.

METHODS

Accordingly, we prospectively analyzed 48 heart transplant receipients referred for routine follow-up from July to September 1998 (age 54+/-11 years, 75% male, 35+/-27 months from transplant). Among these patients, 17 were treated with folate supplementation for 12 months (Group F), while 31 cross-matched for age, gender, serum creatinine and time from transplant (P>0.3 vs Group F for all) did not assume folate supplementation (Group NF). Routine coronary angiography for AVD detection was routinely obtained in every patient.

RESULTS

THcy overall increased during the study period (from 16.6+/-6.5 to 19.4+/-7.6 micromol/l, P<0.001), and a strong trend toward higher THcy was observed in patients presenting AVD (22.4+/-8.7 vs 17.6+/-6.8 micromol/l, P=0.051). After 12 months THcy was lower in Group F as compared to Group NF (16.2+/-5.6 vs 21.1+/-8.1 micromol/l, respectively, P=0.033).

CONCLUSIONS

Our results demonstrate that THcy increases over time in heart transplant recipients, and a strong trend toward higher THcy is observed in the presence of AVD. Since folate supplementation appears to positively influence THcy, a favorable effect of folate on AVD can be hypothesized.

Diagnosis and management of fetal cardiac anomalies: 10 years of experience at a single institution

OBJECTIVE

To assess the diagnostic accuracy of fetal echocardiography and the outcome of cardiac malformations diagnosed in utero.

DESIGN

A retrospective study.

METHODS

The archives of our ultrasound laboratory were searched for fetal cardiac abnormalities in the period 1991-2001.

RESULTS

Diagnosis of a fetal cardiac anomaly was made in 339 pregnancies at a mean gestational age of 26.2 weeks. Pathology or a detailed postnatal follow-up was available in 260 cases, and the prenatal diagnosis was accurate in 236 cases (91%). Discrepancies included nine false positive diagnoses (six ventricular septal defects and three coarctation of the aorta) and 15 cases in which a cardiac anomaly different from the one suspected in utero was documented. Of the 142 fetuses with isolated cardiac malformations (no extracardiac anomalies, normal chromosomes) that were delivered in our center, 114 were alive (80.2%) at a mean follow-up of 38 months (range, 1-120 months). In this group of patients, conotruncal anomalies and univentricular lesions were the most frequent types of anomaly, and had a survival rate of 87% and 57%, respectively. Hypoplastic left heart was the most frequent isolated congenital heart defect in infants that were delivered (19 cases) and it was associated with a survival rate of 37%.

CONCLUSION

In expert hands, fetal echocardiography is highly accurate. The long-term prognosis of cardiac lesions diagnosed in utero is similar to that reported in series of infants diagnosed after birth. The only exception is hypoplastic left heart in which the survival rate is much lower than expected from postnatal studies.

Arrhythmogenic right ventricular cardiomyopathy: clinicopathologic correlation based on a revised definition of pathologic patterns

Different morphologic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) have been described. However, it is still unclear whether they correspond to distinct forms of the same disease. A pathologic study was performed on a series of ARVC (15 from heart transplant and 12 from autopsy) from 2 Italian referral university hospitals. Based on both myocellular features and the nature of myocardial replacement, hearts were divided into 2 groups: infiltrative, with a lacelike pattern of transmural fatty infiltration and strands of normal residual cardiomyocytes (n = 11); and cardiomyopathic, with massive myocardial replacement by fibro fatty tissue and cardiomyopathic changes (such as hypertrophy and myofibril loss) of residual cardiomyocytes (n = 16). Hearts from the infiltrative group were mostly obtained at autopsy of patients who died suddenly. Fatty substitution was limited almost exclusively to the right ventricle. Mitral valve dysplasia (prolapse or cleft) was frequently present. Hearts from the cardiomyopathic group came mainly from heart transplants for congestive heart failure. Fibro fatty replacement was more extensive, usually biventricular. Active myocarditis and features suggestive of myocardial transdifferentiation were also observed. Despite these differences in clinical outcome and morphologic features, patients from the 2 groups showed similar mean age, sex distribution, occurrence of threatening ventricular arrhythmias, and prevalence of family history of sudden death, arrhythmias, or cardiomyopathy. Infiltrative and cardiomyopathic patterns represent different clinical and pathologic subsets of ARVC. Myocellular features are an important clue in the distinction between the two entities. The differentiation between the 2 patterns is feasible on endomyocardial biopsy and could give important prognostic information.

Increasing plasma homocysteine during follow-up in heart transplant recipients: effects of folate and renal function

BACKGROUND

Hyperhomocysteinemia is a common finding in heart transplant recipients and may represent a risk factor for graft failure. However, the time-course, determinants and effects of medical therapy on total homocysteine plasma levels after heart transplantation remain undetermined. The aim of this study was to prospectively analyze 1) the time-course of total homocysteine in heart transplant recipients; 2) the effects of folate supplements and cyclosporine A on total homocysteine; 3) the relation among renal function, serum vitamin levels, and total homocysteine.

METHODS

Fifty-two heart transplant recipients consecutively evaluated for routine follow-up during 1998 were included in the study (mean age 54 +/- 12 years; 28% female). Among the 52 patients, 10 patients were treated with folate for the entire period of the study (Group F), while 26 patients never received folate (Group NF). The remaining 16 patients who did not take folate on a regular basis were excluded from subgroup analysis. Total homocysteine and creatinine plasma levels were assayed at entry into the study (time 0) and at the end of the study, 12 months later (time 12).

RESULTS

Homocysteinemia increased significantly from time 0 to time 12 (p < 0.001), regardless of creatinine plasma levels (p = 0.03) and folate intake (p < 0.01). However, total homocysteine levels were lower in Group F compared to Group NF at time 0 and time 12 (p < 0.02). On multivariate analysis, time of follow-up, serum creatinine and lack of folate intake were positive independent predictors of total homocysteine.

CONCLUSIONS

Homocysteinemia increased over time in heart transplant recipients, regardless of renal function and folate administration. Lower total homocysteine levels were associated with folate intake, suggesting that folate supplements may play a role in the prevention of vascular allograft disease.