Use Of Endomyocardial Biopsy Research Articles

WHEN AND WHERE DOES A CARRIER OF HEREDITARY TRANSTHYRETIN AMYLOIDOSIS (ILE88LEU) SHOW THE FIRST SIGNS OF THE DISEASE? DIAGNOSTIC CHALLENGES OF A NOT ONLY CARDIOGENIC MUTATION

Abstract We present the case of a 58–year–old man with a familiar history (mother affected) positive for ATTR–v (Ile88Leu) amyloidosis. The mother initially had a pure cardiac phenotype and was firstly treated with tafamidis, but progression of the disease to the nervous system warranted a switch to patisiran. Our patient carried the Ile88Leu mutation and had a medical history notable for surgically treated left carpal tunnel syndrome (CTS) and untreated right CTS. Furthermore, he was affected by systemic arterial hypertension and was a habitual smoker. He has been followed at our Institution since 2018. His first echocardiogram showed normal left ventricular ejection fraction (LVEF 65%), mild hypertrophy (anterior septum: 12 mm), and borderline values of GLS (– 16%) without any specific pattern. Further exams were executed: Bone scintigraphy (BS): negative (Perugini score 0); Coronary artery ct scan: moderate stenosis of proximal LAD; Neurologic evaluation: no signs of peripheral neuropathy. The clinical picture remained unaltered in 2020 and 2021. However, during November 2022 the patient developed atrial fibrillation (AF) and presented to the ED for dyspnea and palpitations. Electrical cardioversion was performed with success but subsequent recurrences warranted AF ablation in April 2023. At that moment, the patient was re–evaluated. Basal ECG did not show any significant alteration (FIg.1)This time, echocardiogram showed mild worsening of hypertrophy (13 mm septum), GLS – 16% with apical sparing pattern, no other major variations (Fig.2). BS was repeated and revealed grade 1 Perugini score (Fig.3). Hence, a series of clinical question arose: Should we begin a specific treatment or is the disease in an excessively early stage that does not warrant treatment? Is AF linked to concomitant arterial hypertension or might it be an early marker of disease? We questioned the usefulness of endomyocardial biopsy in this specific setting. In this case, we repeated electromyography that showed mild axonal sensitive–motor polyneuropathy. Finally, we concluded for initial signs of systemic amyloidosis ATTR–v (Ile88Leu) type with mixed phenotype (neurological+cardiac). The neurological involvement allowed us to start a gene–silencer (Patisiran). In conclusion, a periodic neurological evaluation is necessary and has crucial therapeutic implications in all genotypes. Indeed, there is increasing evidence that Ile88Leu is a not only cardiogenic mutation.

Gene-expression profiling of endomyocardial biopsies from dogs with dilated cardiomyopathy phenotype

IntroductionThe employment of advanced molecular biology technologies has expanded the diagnostic investigation of cardiomyopathies in dogs; these technologies have predominantly been performed on postmortem samples, although the recent use of endomyocardial biopsy in living dogs has enabled a better premortem diagnostic approach to study the myocardial injury. Animals, materials, and methodsEndomyocardial biopsies were collected in nine dogs with a dilated cardiomyopathy phenotype (DCM-p) and congestive heart failure and submitted to histologic examination, next-generation sequencing (NGS), and polymerase chain reaction analysis. Data from three healthy dogs (Fastq files) were retrieved from a previously approved study and used as a control group for ribonucleic acid sequencing. ResultsHistologic examination revealed endocardial fibrosis in 6 of 9 dogs, whereas lymphocytic interstitial infiltrates were detected in two of nine dogs, and lymphoplasmacytic and macrophage infiltrates were detected in one of nine dogs. On polymerase chain reaction analysis, two dogs tested positive for canine parvovirus two and one dog for canine distemper virus. Gene-expression pathways involved in cellular energy metabolism (especially carbohydrates-insulin) and cardiac structural proteins were different in all DCM-p dogs compared to those in the control group. When dogs with lymphocytic interstitial infiltrates were compared to those in the control group, NGS analysis revealed the predominant role of genes related to inflammation and pathogen infection. ConclusionsNext-generation sequencing technology performed on in vivo endomyocardial biopsies has identified different molecular and genetic factors that could play a role in the development and/or progression of DCM-p in dogs.

Personalized Management of Myocarditis and Inflammatory Cardiomyopathy in Clinical Practice.

Myocarditis is an inflammatory heart disease induced by infectious and non-infectious causes frequently triggering immune-mediated pathologic mechanisms leading to myocardial damage and dysfunction. In approximately half of the patients, acute myocarditis resolves spontaneously while in the remaining cases, it may evolve into serious complications including inflammatory cardiomyopathy, arrhythmias, death, or heart transplantation. Due to the large variability in clinical presentation, unpredictable course of the disease, and lack of established causative treatment, myocarditis represents a challenging diagnosis in modern cardiology. Moreover, an increase in the incidence of myocarditis and inflammatory cardiomyopathy has been observed in recent years. However, there is a growing potential of available non-invasive diagnostic methods (biomarkers, serum anti-heart autoantibodies (AHA), microRNAs, speckle tracking echocardiography, cardiac magnetic resonance T1 and T2 tissue mapping, positron emission tomography), which may refine the diagnostic workup and/or noninvasive follow-up. Personalized management should include the use of endomyocardial biopsy and AHA, which may allow the etiopathogenetic subsets of myocarditis (infectious, non-infectious, and/or immune-mediated) to be distinguished and implementation of disease-specific therapies. In this review, we summarize current knowledge on myocarditis and inflammatory cardiomyopathy, and outline some practical diagnostic, therapeutic, and follow-up algorithms to facilitate comprehensive individualized management of these patients.

Serum biomarkers of acute rejection: Towards precision medicine in heart transplant

Despite the important changes in the management of heart transplantation in the recent decades, the use of endomyocardial biopsy is still necessary for the follow-up of these patients. However, this technique has several limitations, the most important being the substantial interobserver variability. In the last years multiple attempts have been made to find non-invasive assays for cardiac allograft surveillance, such as imaging modalities and serum biomarkers. This state-of-the-art review focuses on describing the different serum biomarkers that have been proposed for non-invasive diagnosis of acute rejection and that are paving the way towards precision medicine in the field of heart transplantation.

Experience of endomyocardial biopsy from a tertiary care center in India.

Endomyocardial biopsy is the gold standard and has a definite role in the surveillance of cardiac allograft rejection. Its role in other cardiac diseases is limited. However, it is required for conclusive diagnosis of a few entities in which it can influence patient management. There is no reported data regarding the utility of endomyocardial biopsy in the Indian population. Thus, this study was undertaken in a tertiary care center in India to assess the utility of endomyocardial biopsy in various cardiac diseases in the context of clinical diagnoses. All endomyocardial biopsies conducted over a 27-year period were evaluated. Clinical details including indication for biopsy were collected. Histopathological findings were recorded and classified as definitive diagnosis, probable diagnosis with features consistent with the clinical diagnosis, and nonspecific morphological findings. A total of 927 endomyocardial biopsies from 719 patients were reviewed. Endomyocardial biopsy was diagnostic in 12.5% of native cardiac biopsies and 52.1% showed nondiagnostic findings. The most frequent diagnoses were amyloidosis (58.7%) and myocarditis (8.6%). Endomyocardial biopsy had a diagnostic role in evaluation of restrictive cardiac diseases. Endomyocardial fibrosis and tubercular myocarditis, relatively more prevalent in the Indian population, were also identified. Cases of rheumatic heart disease, desmin cardiomyopathy, and microfibrillar cardiomyopathy were surprise findings, proving the usefulness of endomyocardial biopsy in detecting some rare cardiac conditions. Endomyocardial biopsy is an important tool for the diagnosis of specific cardiac diseases including some rare entities, and for conditions which are more prevalent in our country, requiring biopsy confirmation.

Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis

Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.

Acute myocarditis in children: problems of diagnosis and treatment

Acute myocarditis by the World Health Organization is an inflammatory disease of the heart muscle, confirmed by histologically, immunologically and immunohistochemically. The diagnosis of acute myocarditis in children remains open due to the presence of a number of reasons. First of all, it is difficult to diagnose myocarditis in children due to the variety of clinical manifestations and the presence of nonspecific symptoms of the disease. What matters is the lack of accessibility in the routine practice of a doctor of certain research methods and a sharp limitation in the use of endomyocardial biopsy. The search for differential diagnostic algorithms of the disease continues. According to modern literature, much attention is paid to non-invasive methods for the diagnosis of acute myocarditis in children. The course of acute myocarditis can be complicated by life-threatening cardiac arrhythmias: ventricular extrasystole, lengthening of the corrected QT interval, atrioventricular block. The appearance of cardiac arrhythmias increases the risk of sudden cardiac death. Recommendations for the treatment of myocardium in children often undergo changes due to the small number of multicenter and controlled studies in the pediatric population. The article provides an overview of modern approaches to the treatment of acute myocarditis in children: the use of antiviral drugs, intravenous immunoglobulin, immunosuppressive therapy, especially the treatment of heart failure in acute myocarditis in children.

Advanced Morphologic Analysis for Diagnosing Allograft Rejection

Allograft rejection remains a significant concern after all solid organ transplants. Although qualitative morphologic analysis with histologic grading of biopsy samples is the main tool employed for diagnosing allograft rejection, this standard has significant limitations in precision and accuracy that affect patient care. The use of endomyocardial biopsy to diagnose cardiac allograft rejection illustrates the significant shortcomings of current approaches for diagnosing allograft rejection. Despite disappointing interobserver variability, concerns about discordance with clinical trajectories, attempts at revising the histologic criteria and efforts to establish new diagnostic tools with imaging and gene expression profiling, no method has yet supplanted endomyocardial biopsy as the diagnostic gold standard. In this context, automated approaches to complex data analysis problems—often referred to as “machine learning”—represent promising strategies to improve overall diagnostic accuracy. By focusing on cardiac allograft rejection, where tissue sampling is relatively frequent, this review highlights the limitations of the current approach to diagnosing allograft rejection, introduces the basic methodology behind machine learning and automated image feature detection, and highlights the initial successes of these approaches within cardiovascular medicine.

20 Audit on the use of endomyocardial biopsy for diagnosis of non-transplant related cardiac conditions: single centre experience

Background Endomyocardial biopsy (EMB) is an important tool, used in the diagnosis of a wide variety of cardiac conditions. While its role in the surveillance of post-cardiac transplant population is well recognised, its use in the diagnosis of non-transplant related cardiac conditions have not been adequately reported. We report a single centre experience of EMB for non-transplant related indications over a 5 year period. Results A total of 50 EMBs were performed between January 2011 and December 2015.There has been a steady increase in the number of procedures performed during the observed period (Figure 1). The average age for patients undergoing EMB was 56.7 ± 15.1 years, with a significant majority being male (n = 39, 78%). Furthermore, majority of patients requiring EMB presented with symptoms of heart failure (Figure 2). Both femoral and internal jugular veins were used for access with the femoral route being more common (n = 46, 92%).Coronary angiography was performed in 40 (80%) patients. There was no significant difference in the average age between patients who underwent coronary angiography and who did not undergo angiography (56 ± 13.9 vs 59 ± 19.9, p = 0.558). Of the 40 patients who underwent coronary angiography, 11 (27.5%) underwent follow-on EMB. Likewise, cardiac MRI was performed in 40 (80%) patients. In all except one patient, cardiac MRI was performed prior to the EMB procedure. No procedural complications (procedure related mortality, requirement of pericardiocentesis or access related complications) were noted in any of the patients who underwent EMB. EMB provided diagnosis in 14 (28%) cases (Amyloidosis: 10, Lymphocytic myocarditis: 3, Sarcoidosis: 1). Out of the 10 cases of amyloidosis 2 were confirmed only following electron microscopic analysis. Cardiac MRI was indicative of amyloidosis in 8 of the 10 cases. However, it is also important to note that exclusion of specific pathological processes proved important in the management of these patients. Conclusion Our findings demonstrate that the use of EMB for the diagnosis of non-transplant related cardiac conditions is increasing. Our experience demonstrates that the risk of procedural complication is low with none observed during the concerned period.

Use of Endomyocardial Biopsy in Long-Term Follow-up of Patients after Pediatric Heart Transplantation: A Monocentric Experience

Use of Endomyocardial Biopsy in Long-Term Follow-up of Patients after Pediatric Heart Transplantation: A Monocentric Experience

Foreword to special issue on “Myocarditis”

William Osler, with a very actual sentence, stated, back in year 1892, in its Medicine textbook: ‘‘There are three phases to treatment: diagnosis, diagnosis and diagnosis’’ [1]. This sentence clearly highlights that the best clinical management is based upon the most accurate diagnosis. Historically myocarditis has being considered a rare and poorly understood condition, a conundrum with polymorphic clinical presentation and variable prognosis ranging from spontaneous resolution to progressive heart failure and death. The first comprehensive review with a modern approach to etiopathogenesis was published in 1980 by Woodroof JF, who highlighted the possible etiological role of Coxsackie viruses and of the immune system in the progression of cardiac damage, with possible evolution to a dilated cardiomyopathy [2]. A major advance in diagnosis was the refinement of the endomyocardial biopsy technique using the King’s bioptome by Richardson [3]. Another important step was the development of a consensus pathological classification and histological definition of myocarditis by endomyocardial biopsy, known as the Dallas criteria [4]. Meanwhile, the first experimental observations were made by several investigators, suggesting a possible involvement of autoimmune mechanisms to cardiac autoantigens; in particular, a mouse model for myosin-induced autoimmune myocarditis was described by the Neu et al. [5]. In addition, various groups in the late 80s and early 90s reported the presence of circulating anti-heart autoantibodies against myosin as well as other autoantigens in acute and chronic myocarditis or dilated cardiomyopathy, in keeping with the hypothesis of autoimmunity being involved in a subset of patients [6–14]. A retrospective multicenter registry from the USA coordinated by Cooper et al. [15] reported the efficacy of immunosuppressive therapy in a rare but lethal form of myocarditis, e.g., giant cell myocarditis. On these premises, the multicenter Myocarditis Treatment Trial was designed using the Dallas criteria to recruit myocarditis patients to 6 months immunosuppression; the therapy with azathioprine and prednisone or cyclosporine A and prednisone was well tolerated, and no significant effect on survival was observed, although the study was not powered to detect differences in survival [16]. The results of the trial had a profoundly negative effect in the next decade on the use of endomyocardial biopsy to detect and treat myocarditis. However, researchers developed new diagnostic tools to be added to standard histology, in particular immunohistochemistry, to increase sensitivity of endomyocardial biopsy particularly in focal and chronic myocarditis and characterize the number and type of infiltrating inflammatory cells, and molecular detection of genomic material of infectious agents mainly by polymerase chain reaction (PCR), to diagnose infectious, particularly viral myocarditis [17–24]. This work leads to another major step forward, e.g., the 1995 WHO classification of cardiomyopathies, with the acknowledgment that myocarditis is diagnosed on endomyocardial biopsy by established histological, immunological and immunohistochemical criteria; molecular techniques on EMB were recommended to identify viral etiology [25]. In the WHO classification, infectious, autoimmune and idiopathic forms of myocarditis are recognized that may lead to dilated cardiomyopathy [25]. Using serum cardiac autoantibody testing as well as histology, immunohistology and viral PCR on endomyocardial biopsy, it is nowadays possible to define distinct etiopathogenetic A. L. P. Caforio (&) Division of Cardiology, Department of Cardiological, Thoracic and Vascular Sciences, Centro ‘‘V. Gallucci’’, University of Padova-Policlinico, Via Giustiniani, 2, 35128 Padua, Italy e-mail: alida.caforio@unipd.it

The Usefulness of Endomyocardial Biopsy in Patients with Left Ventricular Dysfunction

The Usefulness of Endomyocardial Biopsy in Patients with Left Ventricular Dysfunction

A case of cardiac sarcoidosis : Usefulness of endomyocardial biopsy referred to delayed gadolinium enhanced MRI for diagnosis

A case of cardiac sarcoidosis : Usefulness of endomyocardial biopsy referred to delayed gadolinium enhanced MRI for diagnosis

Demographics, Trends, and Outcomes in Pediatric Acute Myocarditis in the United States, 2006 to 2011

There is a lack of clear diagnostic and management guidelines for acute myocarditis in the pediatric population. We used a multi-institutional database to characterize demographics, practice variability, and outcomes in this population. Patients with acute myocarditis (n=514) were identified from April 2006 to March 2011 using the Pediatric Health Information System database, and regional variations in management and outcomes were analyzed. Ninety-seven patients (18.9%) received extracorporeal membrane oxygenation, 22 (4.3%) received ventricular assist device, 21 (4.1%) received heart transplantation, and 37 (7.2%) died. Of the 104 patients who received extracorporeal membrane oxygenation or ventricular assist device, 17 (16.3%) had heart transplantation, 25 (24%) died, and 62 (59.6%) showed recovery of myocardial function. There was a decrease in the use of endomyocardial biopsy (P=0.03) and an increase in the use of magnetic resonance imaging (P<0.01) over the study period. Although the use of medications and procedures varied between different regions, the occurrence of death or heart transplantation showed no significant regional associations. The use of extracorporeal membrane oxygenation (odds ratio, 5.8; 95% confidence interval, 2.9-11.4; P<0.01), ventricular assist device (odds ratio, 8.2; 95% confidence interval, 2.7-24.9; P<0.01), and vasoactive medications (odds ratio, 5.7; 95% confidence interval, 1.2-26.1; P=0.03) was independently associated with death/transplantation. There is significant temporal and regional variation in the diagnostic modalities and management used for pediatric myocarditis, which continues to have high morbidity and mortality. Extracorporeal membrane oxygenation, ventricular assist device, and vasoactive medications are independently associated with increased mortality/transplantation.

Functional genomics applied to cardiovascular medicine.

Since completion of the draft sequence of the human genome in 2000, the landscape of biomedical research has undergone a rapid transformation. Growing knowledge of genome structure and variation has spawned the development of technologies that allow researchers to study thousands of genes, transcripts, and proteins simultaneously. This has expanded biomedical science beyond reductionist approaches that test the function of individual genes to less biased approaches that study the behavior of many or all genes in homeostasis and disease. Such studies have been grouped under the broad label of functional genomics, which can be defined as the branch of biology that seeks to uncover the properties and function of the entirety of the genes and gene products of an organism.1 Functional genomics is fueling an explosion of new insights in biology and medicine, and many of these insights were completely unanticipated. Because these advances have begun to influence clinical practice,2,3 physicians will be expected to understand the potential uses and limitations of functional genomics in clinical settings. The purpose of this review is to provide a conceptual overview of functional genomics applied to the practice of cardiovascular medicine. We begin with a review of commonly used terms and approaches and then describe examples of their use for screening, diagnosis, and treatment selection in clinical cardiology. We also highlight emerging trends and speculate about where the field is headed in the near term. Although some predictions will be overly optimistic and some major advances unanticipated, we hope this review will help prepare cardiologists for their role in the application of genome science to the diagnosis and treatment of disease. This review is part of a series that introduces several related areas of cardiovascular genetics and genomics.4 We refer to these other contributions to guide further reading …

Dilated Cardiomyopathy With Conduction Disease and Arrhythmia

case presentation: A 48-year-old woman presents with exertional dyspnea and recurrent syncope. One year earlier, a permanent pacemaker was placed after she complained of fatigue and was found to have high-grade atrioventricular block. Now, she has echocardiographic evidence of moderate to severe left ventricular (LV) systolic dysfunction with regional wall-motion abnormalities. Nuclear imaging is notable for heterogeneous myocardial uptake of technetium Tc99m sestamibi, and coronary angiography reveals widely patent epicardial vessels. Multiple episodes of nonsustained ventricular tachycardia (VT) are documented on continuous ECG monitoring. What are the diagnostic considerations for this patient, and what further evaluations are indicated? This patient presents with dilated cardiomyopathy (DCM) with electric instability (DCM+E), which we define as conduction disease and arrhythmia out of proportion to the severity of LV systolic dysfunction. Diverse causes can result in DCM+E and fall into general categories of inflammatory, infectious, hereditary, and infiltrative processes. Cardiac presentation associated with these conditions is distinct from more common causes of DCM such as ischemic heart disease, viral myocarditis, valvular dysfunction, pregnancy, or substance abuse. Clinical features that are suggestive of DCM+E include supraventricular arrhythmias or conduction disease that precedes cardiomyopathy, multiple VT morphologies, and features suggestive of ischemic heart disease (Q waves, regional wall-motion abnormalities, perfusion defects, ventricular aneurysm) in the absence of epicardial stenoses. In this Clinician Update, we focus on the diagnostic approach to patients with DCM+E. Emphasis is placed on diagnoses that are relatively common or for which the clinical management would be impacted significantly by recognition of the underlying cause. Ischemic heart disease may present with conduction disease and a high burden of arrhythmia, especially in the setting of acute myocardial ischemia/infarction. The exclusion of obstructive coronary artery disease is strongly recommended in patients with DCM+E because atherosclerosis is so prevalent, evidence-based treatment is readily available, and the …

The role of endomyocardial biopsy in the management of cardiovascular disease: a commentary on joint AHA/ACC/ESC guidelines

Data on the use of endomyocardial biopsy (EMB) in routine cardiological practice are scant, but anecdotal evidence suggests that its frequency varies substantially between centres. The reasons for this variation...

Classification of Cardiomyopathies and Indication for Endomyocardial Biopsy Revisited

The first classifications of cardiomyopathies from 1980 and 1996 described them as heart muscle diseases, with dilated (DCM), hypertrophic (HCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), and nonclassifiable cardiomyopathies. Furthermore, the World Health Organization/International Society and Federation of Cardiology (WHO/ISFC) classification from 1996 listed among the specific cardiomyopathies inflammatory cardiomyopathy as a new and distinct entity, which was defined histologically as myocarditis in association with cardiac dysfunction. Infectious and autoimmune forms of inflammatory cardiomyopathy were recognized. Viral cardiomyopathy was defined as viral persistence in a dilated heart without ongoing inflammation. If it was accompanied by myocardial inflammation, it was termed inflammatory viral cardiomyopathy (or viral myocarditis with cardiomegaly). This entity was further elucidated in a World Heart Federation consensus meeting in 1999 by quantitative immunohistological criteria (< 14 infiltrating cells/mm(2)) and the etiology by molecular biological methods, e.g., polymerase chain reaction, as viral, bacterial, or autoimmune (= nonmicrobial). The development of molecular genetics, with the discovery of a genetic background in several forms of cardiomyopathies previously alluded to as "of unknown origin", was the origin of a debate on a new classification based on genomics. A genomic/postgenomic classification was postulated taking the underlying gene mutations and the cellular level of expression of encoded proteins into account, thus distinguishing cytoskeleton (cytoskeletalopathies, e.g., DCM or ARVC), sarcomeric (sarcomyopathies as in HCM and RCM) and ion channel (channelopathies, e.g., long or short QT syndrome and Brugada's syndrome) cardiomyopathies. Such a classification of cardiomyopathies was proposed in 2006 by the American Heart Association (AHA), which took the rapid evolution of molecular genetics in cardiology into account. It also introduced several recently described diseases, and is unique in that it incorporated ion channelopathies even without hemodynamic dysfunction as a "primary" cardiomyopathy. The ESC (European Society of Cardiology) Working Group on Myocardial and Pericardial Diseases has deliberately taken a different approach based on a clinically oriented classification in which heart muscle disorders were grouped according to morphology and function. This obviously remains the clinically most useful approach for the diagnosis and management of patients and families with heart muscle disease. In the ESC position statement published in 2008, cardiomyopathies were defined as myocardial disorders in which the heart muscle is structurally and functionally abnormal, and in which coronary artery disease, hypertension, valvular and congenital heart disease are absent or do not sufficiently explain the observed myocardial abnormality. The aim was to help clinicians look beyond generic diagnostic labels in order to reach more specific diagnoses. In parallel, a scientific statement on the role of endomyocardial biopsy in the management of cardiovascular disease was published at the end of 2007 making useful recommendations for clinical practice and providing an understanding for the use of endomyocardial biopsy in an individual patient. Taking the classification of cardiomyopathies and the statement on the role of endomyocardial biopsies in different clinical scenarios together, the clinician is now able to identify genetic, autoimmune and viral causative factors by using a thorough and logical approach to reach a diagnosis in patients with familial and nonfamilial forms of the underlying structural heart muscle diseases.

Hodgkin's disease complicated by cardiomyopathy in two young adults

American Journal of HematologyVolume 82, Issue 6 p. 498-499 Letters and CorrespondenceFree Access Hodgkin's disease complicated by cardiomyopathy in two young adults Lilian Thomas, Lilian Thomas University Hospital at Syracuse, Syracuse, New YorkSearch for more papers by this authorJonathan Wright, Jonathan Wright SUNY University Hospital, Syracuse, New YorkSearch for more papers by this authorNeerja Vajpayee, Neerja Vajpayee SUNY University Hospital, Syracuse, New YorkSearch for more papers by this authorAjeet Gajra, Ajeet Gajra SUNY University Hospital, Syracuse, New YorkSearch for more papers by this author Lilian Thomas, Lilian Thomas University Hospital at Syracuse, Syracuse, New YorkSearch for more papers by this authorJonathan Wright, Jonathan Wright SUNY University Hospital, Syracuse, New YorkSearch for more papers by this authorNeerja Vajpayee, Neerja Vajpayee SUNY University Hospital, Syracuse, New YorkSearch for more papers by this authorAjeet Gajra, Ajeet Gajra SUNY University Hospital, Syracuse, New YorkSearch for more papers by this author First published: 08 January 2007 https://doi.org/10.1002/ajh.20855Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL REFERENCES 1 Petersen CD,Robinson WA,Kurnick JE. Involvement of the heart and pericardium in the malignant lymphomas. Am J Med Sci 1976; 272: 161– 165. 2 McDonnell PJ,Mann RB,Bulkley BH. Involvement of the heart by malignant lymphoma: A clinicopathologic study. Cancer 1982; 49: 944– 951. 3 Gutierrez J,Dighero H,Alarcon G. Myocardial involvement in Hodgkin's disease. Usefulness of endomyocardial biopsy. Report of a case. Rev Med Chil 1991; 119: 308– 311. 4 Chinen K,Izumo T. Cardiac involvement by malignant lymphoma: A clinnicopathologic study of 25 autopsy cases based on the WHO classification. Ann Hematol 2005; 84: 498– 505. Citing Literature Volume82, Issue6June 2007Pages 498-499 ReferencesRelatedInformation

Myocarditis

Myocarditis is clinically and pathologically defined as “inflammation of the myocardium.” Despite its rather clear-cut definition, the classification, diagnosis, and treatment of myocarditis continue to prompt considerable debate. The more routine use of endomyocardial biopsy has helped to better define the natural history of human myocarditis and to clarify clinicopathological correlations. Clinical presentations of the disease range from nonspecific systemic symptoms (fever, myalgias, palpitations, or exertional dyspnea) to fulminant hemodynamic collapse and sudden death. The extreme diversity of clinical manifestations has made the true incidence of myocarditis difficult to determine. Recent prospective postmortem data have implicated myocarditis in sudden cardiac death of young adults at rates of 8.6% to 12%.1,2 Furthermore, it has been identified as a cause of dilated cardiomyopathy in 9% of cases in a large prospective series.3 Recent molecular techniques have facilitated new insights into inflammatory autoimmune processes that affect the myocardium and ultimately result in acute or chronic dilated cardiomyopathy. Despite the well-established morbidity and mortality associated with myocarditis,4–7 clinical practice guidelines with regard to its evaluation and treatment are lacking.8 The wide variety of etiologies implicated in myocarditis and its heterogeneous clinical presentations5,7,9 have impeded patient identification and consensus on the most appropriate diagnostic criteria. The Dallas pathological criteria, published in 1986, served as the first attempt to develop standardized diagnostic guidelines for the histopathological classification of myocarditis.10 Active myocarditis is characterized by an inflammatory cellular infiltrate with evidence of myocyte necrosis (Figure 1), whereas borderline myocarditis demonstrates an inflammatory cellular infiltrate without evidence of myocyte injury (Figure 2). The inflammatory infiltrate should be further described as lymphocytic, eosinophilic, or granulomatous (Figure 3). The amount of inflammation may be mild, moderate, or severe, and its distribution may be focal, confluent, or diffuse, respectively. A retrospective study of 112 consecutive …