Loeffler's Endocarditis Research Articles

Abstract 4127891: Value of Left Ventricular and Left Atrial Strains in Loeffler Endocarditis and Hypereosinophilic Syndrome

Background: Hypereosinophilic syndrome (HES) is a rare disease that causes organ damage and thrombosis due to sustained eosinophilia of the blood or tissues. Loeffler endocarditis (LE) is defined as cardiac involvement in the setting of HES. There are limited data on the diagnostic and prognostic impact of strain imaging on LE. Methods: A single-center retrospective cohort study was performed. Patients with eosinophilia between January 2000 and January 2023 were identified. We included patients who met the current diagnostic criteria for HES and underwent echocardiography prior to treatment. LE was defined as the presence of eosinophils in the myocardium by an endomyocardial biopsy, endocardial thickening, or left ventricular thrombus due to HES. We evaluated the composite events defined as CV death and stroke at diagnosis and during follow-up. Results: Of 1,664 patients with eosinophilia, 34 patients with HES were included (10 with LE and 24 without LE). In the entire cohort, the mean age was 57 ± 16 years and 41% were male. The median follow-up duration was 85 months (25th -75th percentile: 41-145 months). The composite events occurred in 6 patients. Left ventricular ejection fraction (LVEF) was similar in both groups (60% vs. 61%, p = 0.691). Patients with LE had significantly lower left ventricular global longitudinal strain (LV-GLS) (-9.7% vs. -15.5%, p = 0.001), left atrial (LA) reservoir strain (21.0% vs. 32.1%, p = 0.021) and LA conduit strain (-9.7% vs. -19.2%, p <0.001), compared to patients without LE. There were no significant differences in LA booster strain (-11.3% vs. -12.8%, p = 0.606) and right ventricular free wall strain (-17.5% vs. -23.4%, p = 0.083). All LE patients and half of non-LE patients had LV-GLS worse than -16 %. There was a significant difference in the compsoite events for patients with LV-GLS worse than -16% (28.6% vs. 0.0%, p = 0.049). Conclusions: LE was associated with significantly worse LV-GLS and left atrial strain compared to patients without LE. Worse LV-GLS was associated with a higher frequency of the composite events.

Echocardiographic monitoring of myocardial function in a female patient with right heart Loeffler endocarditis at thrombotic stage after Epstein-Barr-virus infection

BackgroundTransthoracic echocardiography is usually the first non-invasive imaging modality for the detection of Loeffler endocarditis at thrombotic stage. In the recent decade 3D echocardiography and deformation imaging already proved as a helpful tool for the monitoring of left and right ventricular heart disease.Case presentationThe present case illustrates the diagnostic role of 3D echocardiography and deformation imaging in the acute stage of right sided Loeffler endocarditis in a 70-year-old Western European (German) woman. This case proves that myocardial involvement due to inflammation can be detected at subclinical stages by speckle tracking echocardiography. Acute deterioration of left and right ventricular function and the early response to prednisolone therapy can objectively be monitored. In addition, alterations of effective stroke volume can quantitatively be assessed by 3D right ventricular volumetry with exclusion of thrombus formation in the volume measurements.ConclusionThis case underlines the importance of 3D echocardiography and deformation imaging as a helpful diagnostic tool in disease management in the acute phase of Loeffler endocarditis at thrombotic stage.

In-Depth Review of Loeffler Endocarditis: What Have We Learned?

Loeffler endocarditis, eosinophilic endocarditis or eosinophilic endomyocardial disease are conditions associated with hypereosinophilia and they affect the heart function. Loeffler endocarditis is a rare endomyocardial disorder thought to be caused by eosinophilic damage. The disorder is characterized by inflammatory infiltration, formation of thrombus within cardiovascular system, and ultimately fibrosis of the afflicted area. It can lead to multiple severe complications, including thromboembolic disease, thickening of fibrous tissue in the endocardium of ventricles, valve involvement, apical obliteration, and various heart disorders. Although early clinical intervention can lead to remission, the underlying mechanisms of the disorder remain unresolved. In the present article, we summarise the existing literature concerning Loeffler endocarditis based on PubMed, Web of Science, and other medical databases to conduct an in-depth review of the epidemiology, etiology, pathophysiological mechanisms, staging, diagnosis, treatment and prognosis of Loeffler endocarditis. Meanwhile, we provide novel patients data and clinical figures of Loeffler endocarditis to supplement the understanding of this cardiac disorder. The findings presented in this article provide a basis for further studies and can be used to improve management of the disorder.

Kiosk 7Q-TA-04 - Multimodality Imaging to Diagnose Loeffler Endocarditis

Kiosk 7Q-TA-04 - Multimodality Imaging to Diagnose Loeffler Endocarditis

Clinical case of a 44-year-old patient with newly diagnosed peripheral T-cell lymphoma unspecified (Lennert’s lymphoma) and Loeffler’s endocarditis

Peripheral T-cell lymphoma unspecified (PTCLu) in most cases has an aggressive clinical course and is characterized by a high frequency of extranodal lesions. One of the manifestations of PTCLu, in particular Lennert’s lymphoma, is eosinophilia. Regardless of the development mechanism, eosinophilia can be accompanied by heart damage, leading to endomyocardial fibrosis, ventricular thrombosis and, in the final stage, to restrictive cardiomyopathies, which are manifestations of Loeffler’s endocarditis (LE). The presence of LE aggravates the course and prognosis of PTCLu, primarily limiting the possibilities of antitumor drug therapy. A multidisciplinary approach to managing a patient with PTCLu and concomitant LE makes it possible to diagnose and start both specific and cardiotropic therapy in a timely manner, ultimately improving the prognosis. A clinical case of a 44‑year-old patient with newly diagnosed PTCLu (Lennert’s lymphoma) and LE is presented.

Contrast Echocardiography with Different Probes: A New Attempt at the Follow-Up of Apical Thrombus in Loeffler Endocarditis.

Contrast Echocardiography with Different Probes: A New Attempt at the Follow-Up of Apical Thrombus in Loeffler Endocarditis.

Systemic thrombo-embolic events in a middle-aged male with Loeffler endocarditis without peripheral eosinophilia—a case report

BackgroundLoeffler-endocarditis (LE) is considered a chronic restrictive cardiomyopathy and manifestation of eosinophilic myocarditis characterized by eosinophilic infiltration. LE is a rare underdiagnosed disease and associated with high morbidity and mortality.Case presentationWe report a case of a 46-year-old man suffering from LE associated with thromboembolic events without peripheral eosinophilia. The patient presented with typical clinical signs of acute onset of limb ischaemia, predominantly on the right limb, indicating immediate iliacal thrombectomy and due to a severe compartment syndrome additional fasciotomy. Total occlusion also of left popliteal artery suggesting an impaired chronic and aggravated impaired perfusion indicated also urgent left sided revascularization. Subsequent echocardiography revealed severe left ventricular dysfunction with a striking amount of spontaneous echo-contrast, noticeable in the left ventricular cavity. Furthermore the initial CT scan demonstrated asymptomatic left kidney- and brain infarctions. Diagnostic workup including endomyocardial biopsy (EMB) of the left ventricle, uncovered an underlying LE without peripheral eosinophilia.ConclusionsThis case demonstrates and highlights the findings, treatment and outcome of a patient with LE and associated thrombo-embolic events without peripheral eosinophilia and emphazises the importance of awareness for LE in patients presenting with an acute cardiac decompensation and thrombo-embolic events. EMB should be performed early in unstable patients unsuitable for cardiovascular magnetic resonance imaging.

Loeffler Endocarditis Causing Heart Failure with Preserved Ejection Fraction (HFpEF): Characteristic Images and Diagnostic Pathway.

We report the case of a 69-year-old female patient in which echocardiography and cardiac magnetic resonance imaging were used to diagnose a patient presenting with heart failure with preserved ejection fraction (HFpEF) due to Loeffler endocarditis. Loeffler endocarditis is an uncommon cause of heart failure with preserved ejection fraction, triggered by eosinophil and lymphocyte infiltration of the endomyocardium, followed by the formation of thrombus in the afflicted area, and eventually fibrosis. This condition is due to an increased number of eosinophils associated with allergies, infections, systemic conditions, as well as malignancies and hypereosinophilic syndrome. Loeffler endocarditis can lead to serious complications, such as progressive heart failure, systemic thromboembolic events, or arrhythmias (including sudden cardiac death).

Hypereosinophilic syndrome onset with Loeffler's endocarditis after COVID-19 infection.

Hypereosinophilic syndrome onset with Loeffler's endocarditis after COVID-19 infection.

Loeffler endocarditis with intracardiac thrombus: case report and literature review

BackgroundLoeffler endocarditis is a relatively rare and potentially life-threatening heart disease. This study aimed to identify the characteristic features of Loeffler endocarditis with intracardiac thrombus on a background of hypereosinophilic syndrome (HES).Case presentationWe described a 57-year-old woman with Loeffler endocarditis and intracardiac thrombus initially presenting with neurological symptoms, who had an embolic stroke in the setting of HES. After cardiac magnetic resonance (CMR), corticosteroids and warfarin were administered to control eosinophilia and thrombi, respectively. During a 10-month follow-up, the patient performed relatively well, with no adverse events. We also systematically searched PubMed and Embase for cases of Loeffler endocarditis with intracardiac thrombus published until July 2021. A total of 32 studies were eligible and included in our analysis. Further, 36.4% of recruited patients developed thromboembolic complications, and the mortality rate was relatively high (27.3%). CMR was a powerful noninvasive modality in providing diagnostic and follow-up information in these patients. Steroids were administered in 81.8% of patients, achieving a rapid decrease in the eosinophil count. Also, 69.7% of patients were treated with anticoagulant therapy, and the thrombus was completely resolved in 42.4% of patients. Heart failure and patients not treated with anticoagulation were associated with poor outcomes.ConclusionsCardiac involvement in HES, especially Loeffler endocarditis with intracardiac thrombus, carries a pessimistic prognosis and significant mortality. Early steroids and anticoagulation therapy may be beneficial once a working diagnosis is established. Further studies are needed to provide evidence-based evidence for managing this uncommon manifestation of HES.

Literature reviews of stroke with hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is defined by persistently elevated blood eosinophil levels and is associated with evidence of organ damage. Cardiovascular involvement in HES is most commonly associated with Loffler endocarditis (cardiac HES). Cardiac HES is typically characterized by progressive subendocardial fibrosis with overlying mural thrombus formation, leading to restrictive dysfunction of the left ventricle. The thrombus from cardiac HES could result in cardiogenic stroke; however, most of the stroke cases with HES were not associated with huge thromboembolism rather multiple infarcts in the watershed area. The major clinical features of 97 previously reported cases of stroke with HES are as follows: the median age was 52 years, of which 61 (63%) were men; the initial presenting symptoms were neurological (73%), followed by headache (16%), respiratory symptoms (9%), and visual symptoms (9%). Almost half of the cases were diagnosed with cardiac HES. The characteristics of cardiac findings were mural thrombi, endomyocardial fibrosis, and a restrictive pattern of heart failure. Cerebral findings revealed 78 cases (80%) were described as multiple infarctions and 55 cases (57 %) were involved with watershed areas, whereas 11 cases (11％) were described as embolic stroke for one proximal large-vessel occlusion. Regarding treatment, 71 (73%), 28 (29%), and 16 (16%) patients were treated with steroids, anticoagulants, and antiplatelets, respectively. The overall mortality and recovery rates were 11% and 89%, respectively. Physicians should know most cases of stroke with HES are characterized by multiple infarctions in the watershed area, and cardiac HES is not always associated with stroke.

Loeffler's Endocarditis Treated with Total Artificial Heart as Bridge to Transplant

<h3>Introduction</h3> We report a case of end-stage Loeffler's endocarditis treated with a total artificial heart as a bridge to transplant. <h3>Case Report</h3> A 34 year old man presented with abdominal distention and weight gain. Multimodality imaging showed near obliteration of the left ventricular cavity in systole with a dilated atria, severe atrioventricular valve regurgitation, and right ventricular dysfunction (Figure A-C). These findings led to the diagnosis of Loeffler's endocarditis (eosinophilic myocarditis) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA). He was treated with diuretics and remained stable for two years before presenting with recurrent weight gain and acute kidney injury with congestive hepatopathy. There was no serologic evidence of autoimmune flare and recent positron emission tomography (PET) imaging showed minimal evidence of active inflammation in the heart. Right heart catheterization revealed elevated right sided filling pressures and severely reduced cardiac output. Given the restrictive nature of his disease, use of diuretics resulted in worsening cardiac output and there was a marginal response to inotropes such that his liver and renal function could not be normalized. Endomyocardial resection and direct transplantation were not options given ongoing liver and renal dysfunction, which put him at prohibitive risk of post-operative fulminant end-organ failure. The patient underwent successful placement of a total artificial heart (TAH; SynCardia Systems, LLC) as a bridge to transplantation. Gross pathology revealed severe endomyocardial fibrosis (D-E). His liver and renal function have normalized and the patient is awaiting heart transplant. <h3>Summary</h3> End-stage Loeffler's endocarditis is a disease with high annual mortality for which medical therapy is insufficient and use of a total artificial heart as a bridge to transplant is a viable option as life-saving therapy.

Löeffler endocarditis due to idiopathic hypereosinophilic syndrome

Abstract Hypereosinophilic syndrome encompasses a heterogenous group of non-hematologic and hematologic disorders defined as peripheral blood eosinophilia &gt;1500/mm3 persisting more than 6 months and eosinophilic end organ complications1,2. Löeffler endocarditis (LE) is the most common cardiac manifestation of the hypereosinophilic syndrome (HES) and represents an acute form of primary restrictive cardiomyopathy3. We report the case of a 74 years-old woman with symptoms related to congestive heart failure and weight loss. At admission the patient had tachycardia and a grade 2/6 systolic mitral murmur. Laboratory findings revealed eosinophilia, hepatocytolysis syndrome and dyslipidemia. The electrocardiogram (ECG) showed non-specific ST-segment and T wave abnormalities. The echocardiography revealed left ventricular apical thrombus and entrapment of chordae tendineae with restricted motion of mitral leaflets leading to mitral regurgitation. The diagnosis of myocarditis was confirmed by the cardiac magnetic resonance imaging which showed the presence of a left ventricular mass with low signal on steady-state free precession imaging and diffuse circumferential subendocardial late gadolinium enhancement (LGE). When discussing the etiology of the HES the following were taken into consideration: hematologic, reactive or secondary disorders. This case is distinguished by diagnosis in an elderly woman and good response to corticosteroid therapy.

Contrast-Enhanced Echocardiography Imaging With a Noncontrast MRI Technique Used in a Patient With Chronic Kidney Disease to Diagnose Loeffler Endocarditis

Loeffler endocarditis is rare and can initially be a clinically silent cardiac disorder. Given its natural history with evolving stages and its vague initial cardiac presentation, it is important to keep this as a differential diagnosis. Without treatment, this disorder is progressive and may lead to a possible restrictive cardiomyopathy-related heart failure. Here, a rare case who presented with nonspecific chest pain is reported, which was recognized early by a routine noninvasive transthoracic echocardiography (TTE) imaging study. This was followed by the addition of contrast enhancement techniques, which made it possible to solidify the diagnosis of the mass to a right ventricular thrombus (possibly secondary to the hypereosinophilia syndrome), with isolated right ventricular involvement. Magnetic resonance imaging (MRI) of the heart, without contrast, was performed to further analyze the anatomic location of this entity. A high index of suspicion for Loeffler endocarditis helped identify this condition.

Follow-up CMR in a case of Loeffler endocarditis.

The typical finding of hypereosinophilic syndrome (Eosinophilic myocarditis) in the delayed enhancement (DE) cardiac magnetic resonance (CMR) is the “double V” sign, which includes (a) normal myocardium, (b) thickened enhanced endomyocardial layer, and (c) overlying apical thrombus. Corticosteroids may result in significant improvement of myocardial involvement.

Loeffler's Endocarditis and Hypereosinophilic Syndrome.

Loeffler's endocarditis and hypereosinophilic syndromes are a unique group of infiltrative disorders characterized by hypereosinophilia, inflammatory thrombotic, and ultimately, fibrotic involvement of the heart leading to multiple complications including valve involvement, thromboembolic phenomena, heart failure. Clinical recognition, comprehensive laboratory and multimodality imaging diagnostic workup, and early initiation of treatment have been shown to slow down the progression and promote remission. This review addresses a detailed analysis of Loeffler's endocarditis and hypereosinophilic syndromes.

Hypereosinophilic Syndrome: What to Expect in Echo

Hypereosinophilic syndrome is characterized by eosinophilic tissue damage. The clinical presentation is variable. When there is cardiac involvement, which occurs in 40%–60% of cases, it is referred commonly as Loeffler's endocarditis. Recently, a unique case report was published by Dr. Garg et al., in which they described pulmonary valve involvement with thickening and stenosis detected by two-dimensional transthoracic echocardiography in an adult presenting with Loeffler's endocarditis. Based on this case report, we review this topic to elucidate various manifestations of hypereosinophilic syndrome, which we should expect during echocardiography.

P1685 Loeffler endocarditis mimicking myocardial infarction

Abstract Loeffler endocarditis is a major cause of morbidity and mortality in patient with hypereosinophilia-associated syndromes. It is a rare disease that occurs due to eosinophilic inflammation of the endocardium with fibrosis and thrombus formation. We describe a case of Loeffler endocarditis with unusual clinical course. 61-year-old woman was admitted due to chest pain and elevated troponin I level. Her past medical history was remarkable for persistent asthma, rhinitis, and productive cough for almost 1 year. Laboratory test revealed hypereosinophilia. Further workup for parasitic diseases, allergy, malignancy, hematological causes were all negative Coronary angiography excluded coronary artery disease. Transthoracic echocardiography (TEE) showed endocardium thickening at the septal left ventricular wall, diastolic dysfunction (Grade II), and moderate pericardial effusion (Figure 1A). Cardiac magnetic resonance imaging (cMR) confirmed endocardial inflammation. The Loeffler endocarditis was diagnosed and corticosteroid treatment was started. After one year the patient was asymptomatic, TEE showed improvement of left ventricular diastolic function (Grade I) and complete regression of myocardial thickening (Figure 1B). Therefore, corticosteroids were slowly tapered. After 16 months she relapsed with severe chest pain, marked eosinophilia and elevated troponin I level. Left ventricular systolic function rapidly deteriorated to ejection fraction of 40%. Urgent cMR showed diffuse edomyocardial inflammation with apical thrombus formation. She was immediately treated with high doses of corticosteroid and heparin, which resulted in systolic function normalization and thrombus disappearance. In conclusion, Loeffer endocarditis still represents diagnostic challenge, may have unpredictable clinical course and generally respond well to corticosteroid treatment in early stages. Abstract P1685 Figure 1.

P681 Surprise imaging findings in an asymptomatic patient with an ECG suggestive of apical hypertrophic cardiomyopathy

Abstract We present the case of a 55-year old woman with an unremarkable past medical history, allergic to eggs and cinnamon and without any clinical complaints, who presented for a routine ECG prior to a dental implant procedure. The ECG revealed signs of left ventricular (LV) hypertrophy with deep negative T waves in V2-V6 (Figure) suggesting apical hypertrophic cardiomyopathy. Her physical exam was unremarkable and a transthoracic echocardiography (TTE) was ordered. The TTE revealed normal LV dimensions, a normal global systolic function of both ventricles, but most remarkably, an isoechoic mass that occupied the whole apex and one third of the LV cavity (Figure), with a maximum thickness of 22 mm and a 2 mm hyperechogenic lining towards the LV, all these findings being suggestive of Loeffler endocarditis. The routine laboratory tests showed (apart from a slightly increased LDL-cholesterol and normal BNP values) hypereosinophilia: more than 10% of the white blood count. Chest X-Ray and the abdominal scan showed no signs of pulmonary or hepatic infiltration. Cardiac magnetic resonance imaging was scheduled, but the patient has claustrophobia and was unable to perform the exam. The aetiological workup included the investigation of allergic, hematologic, as well as parasitic causes of the hypereosinophilic syndrome. Consequently, serological tests for Coxiella, Chlamydia, Echinococcus and Toxocara were all performed. The IgG antibodies for Toxocara canii were found in a very high level, indicating a chronic parasitic infection as a possible cause of the hypereosinophilic syndrome. The hematologic exams were all within normal limits. The endomyocardial biopsy, the gold standard for diagnosis could not be performed for technical reasons. The first step in the management of hypereosinophilia (HE) is stopping exposure to the trigger, as well as specific treatment- albendazole. The patient received oral anticoagulant treatment in order to prevent thromboembolic complications, which are frequently reported in this clinical setting. Loeffler’s endocarditis is usually a late cardiac manifestation of the HE syndrome. This is a rare and surprising case of an incidental imaging diagnosis in a totally asymptomatic patient after a routine ECG that was suggestive of hypertrophic cardiomyopathy. The challenge consisted in finding the cause of HE in order to attempt an aetiological treatment. Although the allergic and parasitic causes were most likely, considering the patient’s history, a hematologic malignancy had to be excluded. HE associated with toxocariasis rarely causes cardiac manifestations, but it should not be excluded when the patient has a history of canine exposure. The most fearsome complication in this case is the embolization of the eosinophilic mass, but the prompt management and routine follow-up allow the prevention of a thromboembolic event. Abstract P681 Figure. ECG and TTE apical views

Loeffler Endocarditis in Idiopathic Hypereosinophilic Syndrome Demonstrated by Magnetic Resonance Imaging Effectively Treated by Corticosteroids.

Hypereosinophilia (HE) is diagnosed with persistent eosinophilia (absolute eosinophil count > 1.5 × 109/L) recorded on two occasions at least 1 month apart.1 If there is evidence of organ damage caused by HE and exclusion of other disorders as the main reason for organ damage, it is defined as hypereosinophilic syndrome (HES). Loeffler endocarditis is a subtype of HES in which the myocardium is involved and considered to be one of the major causes of morbidity and mortality in HES.2 The definite diagnosis of Loeffler endocarditis requires myocardial biopsy, an invasive procedure bearing certain risks, which may not always be available or consented by patients. Echocardiography can assess morphological and functional changes but not myocardial tissue composition. However, cardiac magnetic resonance imaging (MRI) is able to characterize different kind of myocardial damage with satisfying resolution and can be a substitute of biopsy in the diagnosis of Loeffler endocarditis.3-6 In this case, we report an interesting case of Loeffler endocarditis in idiopathic HES, which is demonstrated by cardiac MRI and effectively treated by corticosteroids.