Diagnostic Endomyocardial Biopsy Research Articles

P19 INCIDENTAL DIAGNOSIS OF MASSIVE MOBILE LEFT VENTRICLE THROMBI FOLLOWING COVID–19 INFECTION IN A HEART FAILURE PATIENT

Abstract Background Intracardiac thrombus can be a complication of ischemic heart disease and cardiomyopathies. The advancements in imaging modalities have increased the capacity to diagnose this condition helping to reduce the associated complications (i.e. embolization). Previous reports suggest a possible link between intracardiac thrombosis and COVID–19 infection, especially in patients with severe “endotheliitis”, pneumonia, or myocarditis. COVID–19 effects on the cardiovascular system are partly evaluated. Venous and arterial thrombosis is commonly associated with COVID–19 but detection of intracardiac thrombus has not been frequently reported. Case Description: A 71–year–old woman, known to have a non–ischemic dilated cardiomyopathy with reduced ejection fraction (EF) and a previous transcatheter edge–to–edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars–Cov–2, experienced a paucisymptomatic COVID–19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast echocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses. The largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49x15 mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses’ dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2–week a complete resolution of the masses was documented with no clinical or embolic events. Conclusion The pro–thrombotic nature of COVID–19 infection is well known. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non–severe COVID–19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring and/or the use of anticoagulant therapies could yield a benefit in selected patients.

88 INCIDENTAL DIAGNOSIS OF MASSIVE MOBILE LEFT VENTRICLE THROMBI FOLLOWING COVID-19 INFECTION IN A HEART FAILURE PATIENT

Abstract A 71-year-old woman, known to have a non-ischemic dilated cardiomyopathy with reduced ejection fraction (EF), and a previous transcatheter edge-to-edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars-Cov-2, experienced a paucisymptomatic COVID-19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months before showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast ecocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses; the largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49×15 mm). mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses’ dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2-week a complete resolution of the masses was documented with no clinical or embolic events. Cardiovascular complications of the coronavirus disease have been documented both in the acute phase and in convalescence; one such complication is the formation of LV thrombus; the pro-thrombotic nature of COVID-19 infection is well known: the coagulation activation mechanism is currently uncler, but it might be correlated to excessive inflammation, COVID-induced hypoxia, direct cytopathic effects on the cardiac endothelial cells, immobilization. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non-severe COVID-19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring could yield a benefit in selected patients; current guidelines do not support the use of anticoagulation prophylaxis for non-severe COVID.19, but further studies regarding anticoagulant prophylaxis for COVID-19 patients with chronic heart diseases, including DCM, are warranted.

COVID-19 and Myocarditis: Review of Clinical Presentations, Pathogenesis and Management.

There are four main myocarditis presentations identified in the context of severe acute respiratory coronavirus 2 (SARS-CoV-2): myocarditis associated with acute coronavirus disease 2019 (COVID-19) infection, post-acute COVID-19 syndrome, multisystem inflammatory syndrome, and vaccination-associated myocarditis. This article reviews the clinical features and current management strategies for each of these presentations. The overall prevalence of myocarditis is considered to be rare, although accurate estimation is affected by heterogeneity in diagnostic criteria and reporting, as well as infrequent use of gold-standard diagnostic endomyocardial biopsy. Severity of disease can range from mild symptoms to fulminant myocarditis. Therapeutic interventions are typically supportive and extrapolated from treatment for non-COVID-19 viral myocarditis. Several pathogenic mechanisms for the development of myocarditis have been proposed, and ongoing research is critical for elucidating disease pathogenesis and potentially identifying therapeutic targets. The long-term cardiovascular sequelae of SARS-CoV-2 infections and associated myocarditis require further elucidation and understanding.

Cardiomyopathie toxique induite par l’hydroxychloroquine compliquant le traitement d’un lupus systémique

Hydroxychloroquine (HCQ) is considered as efficient and safe to treat systemic lupus. We report a case of fatal toxic cardiomyopathy, an underrecognized adverse effect of HCQ. A 72-year-old woman with systemic lupus erythematosus treated for 24 years by HCQ received a kidney allograft. One year later she developed a cardiomyopathy with conductive disorders. An endomyocardial biopsy showed severe non-specific myocardial fibrosis and hypertrophic vacuolated myocytes. Transmission electron microscopy showed curvilinear bodies and pseudomyelin figures consistent with HCQ-induced cardiomyopathy. At immunohistochemistry LC3b, p62 and beclin-1 accumulated in vacuolated cardiac myocytes suggesting impaired cell autophagy. When unexplained cardiac disease develops in patients receiving long-term HCQ treatment, toxic cardiomyopathy should be considered leading to a diagnostic endomyocardial biopsy.

Endomyocardial biopsy guided by intracardiac echocardiography as a key step in intracardiac mass diagnosis

BackgroundBased on a plenty of different applications, intracardiac echocardiography (ICE) is now a well-established technology in complex electrophysiological procedures. Recently, ICE has become the most widely used ultrasound-based imaging tool to guide diagnostic endomyocardial biopsy (EMB). EMB of cardiac mass guided by ICE is an interesting application of ICE. Allowing a correct positioning of the bioptome, ICE reduce the procedure-related risks and the need of a diagnostic open-chest procedure reserving the more invasive approach to selected cases.Case presentationHereby we report a case series of right ventricular masses in which the EMB was safely and effectively performed under ICE guidance giving essential information for planning the therapeutic strategy.ConclusionsThe diagnosis of both metastatic and primary cardiac tumors relies on the histopathological analyses. The endomyocardial biopsy is a valuable tool for preoperative diagnosis and surgical planning of intracardiac masses suspected for tumors. In our experience, the use of ICE for right ventricle EMB of an intracardiac mass is an attractive modality thanks to the precise localization of the cardiac structures and the ability to guide bioptic withdrawal in the target area.

Mitochondrial disease is a common cause of severe cardiomyopathy in children

AimsRespiratory chain abnormalities have been documented in children with idiopathic cardiomyopathy undergoing diagnostic endomyocardial biopsy.1 Mitochondrial disease can present with isolated cardiomyopathy or prominent cardiac involvement in multisystem disease, but...

Orbital myositis, vitiligo, and giant cell myocarditis

Giant cell myocarditis is a rare idiopathic inflammatory heart disease characterized histologically by multinucleated giant cells, and clinically by rapid progressive heart failure, arrhythmias, or sudden death, often within hours to days of initial symptoms. There are two previously reported cases of giant cell myocarditis with idiopathic orbital myositis. We report a similar case in a patient who also had vitiligo, a diagnostic endomyocardial biopsy, and survival because of a cardiac transplant. Giant cell myocarditis should be monitored for in the course of inflammatory orbital myopathy because of its life-threatening fulminant course.

Antimyosin Scintigraphy for Detection of Myocarditis: Scintigraphic Follow-up

To examine the value of antimyosin-indium 111 imaging in relation to endomyocardial biopsy in patients with suspected myocarditis, as well as the natural evolution of abnormal findings on the antimyosin scan, 12 patients with suspected myocarditis underwent endomyocardial biopsy and antimyosin scan. The heart-to-lung ratio (H/L) was used to quantify the antimyosin scan. All 12 patients had abnormal results on the scan (H/L, 1.7 to 2.9; mean, 2.1 +/- 0.3); 8 of the 12 patients also had a diagnostic endomyocardial biopsy. In four patients with abnormal findings on antimyosin scan and normal findings on biopsy, the H/L ratio did not differ from eight patients with abnormal findings on antimyosin scan and a diagnostic biopsy; also, the ejection fraction did not differ between the two groups. One patient died, and 8 patients had a repeat antimyosin scan within 2 months after the initial study. The H/L ratio returned to normal in two out of three patients with normal results on biopsy and in three out of five patients with a diagnostic biopsy; the ejection fraction improved by 8 percent or more in one out of three patients with a nondiagnostic biopsy and in two out of five patients with a biopsy diagnostic for myocarditis. We conclude that the antimyosin scan is more frequently diagnostic than biopsy in suspected myocarditis. Patients with abnormal results on antimyosin scan and a nondiagnostic biopsy, as well as those with abnormal results on antimyosin scan and a diagnostic biopsy, tend to return to normal results on scan within 2 months and improve their ejection fraction.