Heart Failure Of Unknown Cause Research Articles

Does the lack of late gadolinium enhancement using magnetic resonance imaging eliminate coronary artery disease in patients presenting with systolic heart failure of unknown cause?

Does the lack of late gadolinium enhancement using magnetic resonance imaging eliminate coronary artery disease in patients presenting with systolic heart failure of unknown cause?

Left Hemiplegia: An Unusual Presentation of Peripartum Cardiomyopathy (PPCM)

PPCM is a rare form of heart failure of unknown cause with a reported incidence of 1 per 4,000 live births. Onset is usually between the last month of pregnancy and up to fifth month postpartum in previously healthy women, with a reported fatality rate of 20–25 %. Risk factors for PPCM include multiparity, older maternal age, black color, preeclampsia and twin pregnancies. Its aetiology remains unknown though viral, autoimmune and idiopathic factors may be contributory. 75 % cases present first month postpartum which suggests an autoimmune cause rather than the pregnancy exacerbating a pre-existing cardiomyopathy. PPCM usually presents initially with signs and symptoms of heart failure and rarely with thromboembolic complications. Left ventricle mural thrombus common after acute myocardial infarction but rare in PPCM. The management of PPCM is similar to that of any other forms of dilated cardiomyopathy. True incidence of thromboembolism in PPCM is not known which needs further research. We report an unusual case of PPCM in a previously healthy woman who presented with features of heart failure and left hemiplegia due to thromboembolism.

Anitschkow cells in the human heart

A case of multiple myeloma, who died of congestive heart failure of unknown cause, is presented. Microscopically, Anitschkow cells with caterpillar and owl-eyed nuclei were scattered in the interstitium of the myocardium. To know the pathological significance of their appearance, histological observations of normal, developing and autoimmune disease-bearing heart specimens were made. A few Anitschkow cells were commonly seen in the interstitium of the adult heart with or without autoimmunity, and fetal cardiomyocytes often showed Anitschkow-type nuclear configurations. Moreover, squamous cancer cells metastatic to the myocardium exhibited Anitschkow-type nuclei. No Anitschkow-type nuclei were observed in extracardiac locations. In conclusion, formation of Anitschkow-type nuclear features in the human heart is not necessarily specific to the autoimmune status, but can be regarded as being ubiquitously provoked by the continuous contraction of heart muscle cells.

Clinical aspects of virus/immune myocarditis.

SummaryAlthough a cause-and-effect relationship between viral infection and myocarditis remains inferential, two distinct clinical syndromes can be identified. During the early viral phase, the cardiac manifestations emerge while the symptoms of active viral infection are also present. During the chronic phase, symptoms of the viral infection may be remote or nonexistent, and identification of active myocarditis is contingent upon an aggressive diagnostic approach with endomyocardial biopsy and gallium 67 imaging. The exact incidence of myocarditis in patients with heart failure of unknown cause is unclear due to lack of standardization of histologic parameters. There are no other clinical clues to the presence of myocarditis in those patients presenting with cardiomyopathy or ventricular arrhythmia. For further clarification of the incidence and various presentations of myocarditis a large multi-center trial is necessary.

Prognosis and treatment of cardiomyopathy and myocarditis.

Dilated cardiomyopathy is a heterogeneous group of disorders with a prognosis that is dependent upon the severity of presenting clinical and hemodynamic abnormalities. Although this condition is characterized by a high mortality, spontaneous improvement is noted in 25% of cases. Standard therapeutic modalities are nonspecific and consist of the therapy of congestive heart failure and ventricular arrhythmia. Recent studies suggest that beta blockade and cardiac transplantation may soon become accepted modalities in this condition. Acute viral myocarditis is a common disease that has a good prognosis, however occasionally progression to chronic myocardial disease has been identified. The therapy of acute viral myocarditis should be limited to symptomatic treatment, anti-coagulation, and bed rest. When chronic myocarditis is identified on endomyocardial biopsy in patients with heart failure of unknown cause, the treatment differs little from that of dilated cardiomyopathy with the exception that recognizing that efficacy has not been proven; immunosuppressive therapy may be added in life-threatening situations. Future studies will be directed at further clarification of the prognosis of each of these conditions with intensive evaluation of the role of beta blockade and immunosuppression.

Occult aortic stenosis as cause of intractable heart failure

During a three-year period 10 patients with critical aortic stenosis were referred to a cardiac referral centre with symptoms and signs of intractable cardiac failure and low cardiac output. In nine patients the correct diagnosis was not suspected at the referring hospital, and in the remaining patient the true severity of the aortic stenosis was not appreciated and cardiomyopathy was suggested as an additional diagnosis. The most common referral diagnoses were severe mitral regurgitation (four patients), congestive cardiomyopathy (two patients), or both (three patients). Only two patients had soft ejection systolic murmurs at the base of the heart radiating into the neck, and such a murmur appeared in a third patient during medical treatment. The carotid pulses were of small volume but the characteristic slow-rising, anacrotic nature of the pulse could not be appreciated clinically. The diagnosis was suspected in nine patients because of aortic valve calcification detected by lateral chest x-ray examination in seven patients and by x-ray screening of the heart in two, and because of abnormal aortic valve echoes in the echocardiogram of all five patients in whom the aortic valve could be seen. Eight patients underwent aortic valve replacement despite seemingly poor preoperative left ventricular function. Three patients died, of whom two had severe coexistent coronary artery disease. The five survivors all returned to normal lives and needed little or no medication.Critical aortic stenosis should be actively sought in patients with severe heart failure of unknown cause since surgery may enable them to resume their normal lives.

Two dimensional echocardiographic assessment of patients with bioprosthetic valves

The clinical utility of two dimensional echocardiography in assessing bioprosthetic and left ventricular function was studied in 40 consecutive patients 1 week to 60 months after valve replacement surgery. These patients were referred to obtain normal baseline studies as well as to evaluate complications:suspected endocarditis, embolic phenomena and congestive heart failure of unknown cause. Independent M mode echocardiograms were also obtained in each patient. Confirmation of ultrasonic studies was by cardiac catheterization with angiography, surgery and pathologic study in 10 patients; cardiac catheterization with angiography alone in 7 patients; surgery and pathologic study in 3 patients; autopsy in 3 patients; blood cultures to confirm or exclude endocarditis in 10 patients; and confirmation on clinical grounds in 7 patients. Technically adequate two dimensional studies were recorded in 39 of 40 subjects. Two dimensional echocardiography accurately assessed 15 of 16 patients with an abnormal bioprosthetic valve and a normal left ventricle (1 of 16 patients had a false positive two dimensional echocardiogram); 8 of 8 patients suspected to have prosthetic valve or left ventricular dysfunction but who were normal; 7 of 7 patients with a normal prosthesis and an abnormal left ventricle; the one patient with an abnormal valve and left ventricle; and 7 of 7 clinically normal patients who were referred for baseline studies. In summary, the two-dimensional echocardiogram demonstrated a 97 percent diagnostic accuracy rate which was significantly greater than the 67 percent (P less than 0.001) for M mode echocardiography in the same group of patients. It is concluded that two dimensional echocardiography has excellent diagnostic accuracy in assessing bioprosthetic and left ventricular function and is superior to M mode echocardiography in evaluating patients after such valve replacement.