Ventricular Endomyocardial Biopsy Research Articles

Eosinophilic myocarditis without hypereosinophilia accompanied by giant cell infiltration

A 53-year-old woman with a history of allergic disease was admitted to our hospital because of syncope induced by sustained ventricular tachycardia. The clinical course and the laboratory data did not correspond to those of acute myocarditis. Although eosinophils in the peripheral blood count were not increased, the diagnosis of eosinophilic myocarditis was made following a right ventricular endomyocardial biopsy that showed a remarkable infiltration of eosinophils. While giant cells were another histopathological feature of this case, they were considered to be an expression of the disease severity. This is a rare case of eosinophilic myocarditis, without peripheral eosinophilia.<Learning objective: Eosinophils in the peripheral blood usually increase in eosinophilic myocarditis. We describe a case of eosinophilic myocarditis without hypereosinophilia. Even in the absence of hypereosinophilia, endomyocardial biopsy should be performed during the investigation of unexplained myocardial disease.>

Transradial left ventricular endomyocardial biopsy: assessment of safety and efficacy.

We aimed at assessing the safety and efficacy of a systematic transradial approach for left ventricular endomyocardial biopsy using a new hydrophilic sheathless guiding catheter. Forty-two consecutive patients were included. The transradial success rate was 98% (41 of 42). In one case, cross over to femoral access due to irreversible spasm of the right radial artery was necessary. No radial spasm was observed in the other 41 patients. Depending on the indication, several other procedures, such as coronary angiography or ventricular angiography, were additionally performed through the same transradial access site. Median fluoroscopy time was 7.9 min. The mean dose area product was 1867 cGy × cm(2). All biopsy samples were graded as good or excellent quality. No patient had any complications. Immediate post-procedural ambulation could be achieved in all patients. Radial artery patency was confirmed by duplex sonography 24 h after removal of the guide. The present study demonstrates safety and efficacy of a systematic transradial access for left ventricular EMB using a highly hydrophilic sheathless guiding catheter. This is of clinical importance since this new technique may overcome critical limitations of the common approach.

Feasibility and safety of left ventricular endomyocardial biopsy via transradial access: Technique and initial experience.

Endomyocardial biopsy constitutes an essential part of the diagnostic algorithm in patients with heart failure of unknown origin, but usually requires transfemoral access. Here, we describe a novel method that allows interventional cardiologists to obtain left ventricular biopsies via transradial access with a 7.5F sheathless multipurpose (MP1.0) guiding catheter. This approach was successfully conducted in 37 consecutive patients at our institution with only one intraprocedural minor complication (ventricular fibrillation during insertion of the guiding catheter). Transradial access to obtain left ventricular endomyocardial biopsies is a feasible and safe option for experienced radial operators.

Focal myocardial fibrosis assessed by late gadolinium enhancement cardiovascular magnetic resonance in children and adolescents with dilated cardiomyopathy.

BackgroundDifferent patterns of late gadolinium enhancement (LGE) including mid-wall fibrosis using cardiovascular magnetic resonance (CMR) have been reported in adult patients presenting with non-ischemic dilated cardiomyopathy (DCM). In these studies, LGE was associated with pronounced LV remodelling and predicted adverse cardiac outcomes. Accordingly, the purpose of our study was to determine the presence and patterns of LGE in children and adolescents with DCM.MethodsPatients <18 years of age presenting with severe congestive heart failure who were admitted for evaluation of heart transplantation at our centre underwent CMR examination which consisted of ventricular functional analysis and assessment of LGE for detection of myocardial fibrosis. Ischemic DCM was excluded by coronary angiography, and right ventricular endomyocardial biopsies ruled out acute myocarditis.ResultsThirty-one patients (mean age 2.1 ± 4.2 years) with severe LV dilatation (mean indexed LVEDV 136 ± 48 ml/m2) and LV dysfunction (mean LV-EF 23 ± 8%) were examined. LGE was detected in 5 of the 31 patients (16%) appearing in various patterns characterized as mid-wall (n = 1), focal patchy (n = 1), RV insertion site (n = 1) and transmural (n = 2). Based on histopathological analysis, 4 of the 5 LGE positive patients had lymphocytic myocarditis, whereas one patient was diagnosed with idiopathic DCM.ConclusionsIn children and adolescents with DCM, focal histologically proven myocardial fibrosis is rarely detected by LGE CMR despite marked LV dilatation and severely depressed LV function. LGE occurred in various patterns and mostly in patients with inflammatory cardiomyopathy. It remains unclear whether myocardial fibrosis in childhood DCM reflects different endogenous repair mechanisms that enable favourable reverse remodelling. Larger trials are needed to assess the prognostic implications of LGE in childhood DCM.

Abstract 17315: Low Occurrence of Left Ventricular Reverse Remodeling and Poor Long-term Prognosis in Dilated Cardiomyopathy with Higher Immunohistological Expression of Myocardial Tenascin-C

Background: Tenascin-C (TN-C) is an extracellular matrix protein, and may regulate matrix organization during tissue remodeling. Although serum TN-C is reported as a prognostic biomarker in patients with dilated cardiomyopathy (DCM), the clinical significance of myocardial expression of TN-C remains undetermined. The objective of this study is to clarify the significance of myocardial TN-C expression on left ventricular (LV) remodeling and long-term prognosis in patients with DCM. Methods: Eighty consecutive patients in 2005 and 2006, who were diagnosed with DCM by excluding ischemic cardiomyopathy and secondary cardiomyopathy by coronary angiography and right ventricular endomyocardial biopsy, were analyzed. Those patients were followed up to 73±34 months, and their clinical data were obtained. Immunohistochemistry for TN-C was performed on stored biopsy specimens to examine the association of TN-C deposition with the occurrence of LV reverse remodeling as well as long-term mortality. Immunostained area of myocardial TN-C was measured densitometrically and calculated in percent by the fraction of TN-C stained area to the whole myocardium (TN-C area). LV reverse remodeling was defined as LV end-diastolic dimension ≤55 mm and fractional shortening ≥25% by 60 months after diagnosis. Results: TN-C area was 1.2±1.6% on average. Twenty-two patients (28%) underwent LV reverse remodeling. Patients with LV reverse remodeling showed less TN-C area at diagnosis than those without (TN-C area; 0.6±0.5 vs. 1.5±1.8%, p=0.021). Patients were divided into two groups according to the extent of TN-C area; high TN-C group (TN-C area≥1.5%, n=19) and low TN-C group (TN-C area&lt;1.5%, n=61). LV reverse remodeling occurred less frequently in high TN-C group compared with low TN-C group (5% vs 33%, p=0.01). Eleven patients (14%) died during the observation period. Kaplan-Meier analysis revealed high TN-C group had worse prognosis than low TN-C group (p=0.009). Conclusions: Patients with higher immunohistological expression of myocardial TN-C in DCM were characterized with lower occurrence of later LV reverse remodeling and poorer long-term prognosis. Myocardial TN-C may have some crucial role in LV remodeling process in patients with DCM.

Plakoglobin immunolocalization as a diagnostic test for arrhythmogenic right ventricular cardiomyopathy.

A recent study using an anti-plakoglobin antibody and immunofluorescence methods in endomyocardial tissue specimens found that a marked reduction in plakoglobin staining was highly sensitive and specific for the diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). The purpose of our study was to determine the diagnostic utility of plakoglobin immunolocalization using more standard immunoperoxidase methods suitable for clinical laboratories. Between January 2007 and October 2010, all patients at our center with suspected ARVC underwent noninvasive and genetic testing, right ventricular (RV) angiography, electrophysiologic studies, and endomyocardial biopsy from the RV septum. Several studies using anti-plakoglobin antibodies were performed using standard immunoperoxidase methods at concentrations of 1:50,000 and 1:75,000 after serial dilutions. Among 16 patients, nine patients fulfilled the clinical criteria for ARVC, and seven patients were found to have other cardiac diagnoses. In the initial study (1:50,000) only one of nine ARVC patients showed reduced plakoglobin signal while the others had normal staining. On repeat staining (1:75,000), reduced signal was observed in three of five of the ARVC patients compared to none in controls (four patients did not have adequate tissue for the repeat experiment). These results confirm that abnormal plakoglobin staining can differentiate biopsies from patients with ARVC from those with other myopathies, but with low sensitivity. Further, each specimen must be studied at a particular concentration due to variable antibody reactivity. The necessity for such fine-tuning of the reaction, as well as the subjectivity involved in interpretation of the results, would make this method difficult to utilize in routine hospital laboratories.

44-Year-Old Man With Exertional Dyspnea, Weight Loss, and Palpitations

44-Year-Old Man With Exertional Dyspnea, Weight Loss, and Palpitations

Stiffness of left ventricular cardiac fibroblasts is associated with ventricular dilation in patients with recent-onset nonischemic and nonvalvular cardiomyopathy.

Ventricular dilation is known as a pivotal predictor in recent-onset cardiomyopathy (ROCM), but its pathophysiology is not fully understood. In the present study we investigated whether single-cell stiffness of right and left ventricular-derived fibroblasts has an effect on cardiac phenotype in patients with ROCM. Patients with endomyocardial biopsy-proven ROCM were included (n=10). Primary cardiac fibroblasts (CFBs) were cultured from left and right ventricular endomyocardial biopsies and their single-cell stiffness was analyzed by quantification of Young's modulus using colloidal probe atomic force microscopy. Cardiac fibrosis was analyzed by Masson's trichrome staining. CFBs from the left ventricle showed significantly decreased stiffness when compared with CFBs from the right ventricle, indexed by decreased stiffness (Young's modulus 3,374±389 vs. 4,837±690 Pa; P<0.05). Young's modulus of CFBs derived from the left ventricle correlated negatively with the left ventricular end-diastolic dimension derived from 2-dimensional echocardiography (R(2)=0.77; P<0.01). Neither left nor right ventricular fibrosis correlated with the respective ventricular dimensions. Our data suggest that a decrease in single-cell stiffness of left ventricular fibroblasts could trigger left ventricular dilation in patients with ROCM. This implies a new potential mechanism for the ventricular dilation with this disease.

Neopterin and beta-2 microglobulin relations to immunity and inflammatory status in nonischemic dilated cardiomyopathy patients.

Background. The aim of the study was to assess the relationships among serum neopterin (NPT), β2-microglobulin (β2-M) levels, clinical status, and endomyocardial biopsy results of dilated cardiomyopathy patients (DCM). Methods. Serum NPT and β-2 M were determined in 172 nonischaemic DCM patients who underwent right ventricular endomyocardial biopsy and 30 healthy subjects (ELISA test). The cryostat biopsy specimens were assessed using histology, immunohistology, and immunochemistry methods (HLA ABC, HLA DR expression, CD3 + lymphocytes, and macrophages counts). Results. The strong increase of HLA ABC or HLA DR expression was detected in 27.2% patients—group A—being low in 72.8% patients—group B. Neopterin level was increased in patients in group A compared to healthy controls 8.11 (4.50–12.57) versus 4.99 (2.66–8.28) nmol/L (P < 0.05). β-2 microglobulin level was higher in DCM groups A (2.60 (1.71–3.58)) and B (2.52 (1.51–3.72)) than in the control group 1.75 (1.28–1.96) mg/L, P < 0.001. Neopterin correlated positively with the number of macrophages in biopsy specimens (P < 0.05) acute phase proteins: C-reactive proteins (P < 0.05); fibrinogen (P < 0.01); and NYHA functional class (P < 0.05) and negatively with left ventricular ejection fraction (P < 0.05). Conclusions. Neopterin but not β-2 microglobulin concentration reflected immune response in biopsy specimens. Neopterin correlated with acute phase proteins and stage of heart failure and may indicate a general immune and inflammatory activation in heart failure.

Heart Failure in Which Coronary Spasms Played an Important Role

A 69-year-old woman was admitted for further examinations and treatment of chest pain. Emergency cardiac catheterization showed no significant stenosis on coronary angiograms; however, diffuse wall hypokinesis was observed on a left ventriculogram. After treating the patient's heart failure, cardiac catheterization was performed again. A spasm provocation test showed coronary spasms of the right and left coronary arteries. A right ventricular endomyocardial biopsy revealed denaturation and fibrosis of the myocardium under the endocardium, thus suggesting the presence of myocardial ischemia. This case highlights coronary spasms as a cause of heart failure.

‘Crystal’ in the heart

A 35-year-old man presented to the emergency unit with progressive dyspnoea of two weeks’ duration. He had no previous medical history, and denied chest discomfort. During echocardiography, a severely impaired biventricular systolic function with severe atrioventricular valve insufficiency was found. The left ventricular end diastolic diameter (LVEDD) was 74 mm (Fig. 1A). There was no evidence of coronary artery disease (CAD), as shown in Figure 1B. On inquiry, he confessed to a weekly consumption of ‘crystal’ (methyl amphetamine) of about 0.5–1 g. Haemodynamic findings showed a decreased cardiac index of 1.7 L/min/m2. The patient had an intra-aortic balloon pump implanted as a bridge to recovery. However, haemodynamic and echocardiographic parameters did not improve, so he received a levosimendan infusion. Left ventricular endomyocardial biopsies were taken, and histological and immunohistological examinations revealed severe methamphetamine-induced chronic myocardial injury with degeneration of hypertrophied myocytes neighbouring small arterioles with medial hyperplasie in the presence of a mild inflammatory reaction (Fig. 1D). There was no evidence of acute or chronic myocarditis, amyloidosis or preexisting dilated or other primary cardiomyopathies. No viral genomes were detected by nested PCR analysis. The results were confirmed by cardiac magnetic resonance imaging (MRI) (Fig. 1C). Late gadolinium enhancement indicating myocardial fibrosis or necrosis was not obvious. The patient slowly recovered over the course of two weeks. Long-term ECG showed a non-sustained ventricular tachycardia of 18 beats. He left hospital with a wearable cardioverter-defibrillator (LifeVest®). Chronic use of methyl amphetamine may result in severe heart failure, malnutrition, infections and permanent psychiatric illness. The patient was discharged for outpatient drug rehabilitation.

Contribution and Risks of Left Ventricular Endomyocardial Biopsy in Patients With Cardiomyopathies

Background— Use of left ventricular (LV) endomyocardial biopsy (EMB) to investigate cardiomyopathies is currently discouraged because it is considered riskier than and as contributive as right ventricular (RV) biopsy. The aim of our study is to report our experience with this option and to discuss its advantages and disadvantages. Methods and Results— In our center from 1983 to 2010, 4221 patients underwent diagnostic EMB. In particular, 2396 (56.8%) underwent biventricular EMB, 1153 (27.3%) underwent selective LVEMB, and 672 (15.9%) underwent selective RVEMB. The rate of complications and histological findings were retrospectively analyzed. The periprocedural major complication rate (perforation with or without cardiac tamponade, embolization) was 0.33% for LVEMB and 0.45% for RVEMB, with a significant decrease in the rate of major complications with time (from 1.6% and 1.9% in 1983–1988 to 0% and 0.3% in 2007–2013, respectively; P &lt;0.001 for both), denoting a steep learning curve. No patients died. When the structural and functional abnormalities affected exclusively the LV, the diagnostic yield of LVEMB was 97.8% compared with 53% for RVEMB. Conversely, when the echocardiographic presence of increased wall thickness, local or global ventricular dilation, or dysfunction also involved the RV, the diagnosis was reached in 98.1% of LVEMBs and 96.5% of RVEMBs. This discrepancy was particularly evident for myocarditis, whereas in infiltrative and storage diseases, the histological abnormalities were always detectable in both ventricles. Conclusions— LVEMB is a safe procedure with very low transient complications, comparable to RVEMB. It appears diagnostically more contributive than RVEMB in patients with cardiomyopathies and clinically preserved RV.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Autonomic Dysfunction in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy: Biochemical Evidence of Altered Signaling Pathways

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an important cause of sudden cardiac death especially in times of increased sympathetic tone, for example, during sports, which have been confirmed by nuclear imaging studies. However, the underlying biochemical pathways remain to be delineated. Therefore, we investigated the expression levels of proteins of the signaling cascade in patients with ARVC. During diagnostic work-up, right ventricular endomyocardial biopsies (EMBs) were sampled from 15 consecutive male ARVC patients (52 ± 14 years). Tissue levels of key proteins of the signaling cascade were analyzed. Results were compared to those obtained from EMBs of 10 patients with idiopathic right ventricular outflow-tract tachycardia (RVOT; 41 ± 14 years) and of five control subjects without identifiable structural heart disease (42 ± 13 years; P = ns). Among the proteins analyzed, only tissue levels of norepinephrine (NE; P < 0.04) and cyclic adenosine-3´,5´-monophospate (cAMP; P < 0.01) were significantly lower in ARVC when compared to RVOT patients. When compared to controls, mean cAMP levels were lower in patients with ARVC but did not reach statistical significance. No differences in cAMP were observed between RVOT and controls. The current findings confirm and expand the concept of adrenergic dysfunction in ARVC: the reduction of NE in ARVC could lead to an impaired stimulation of β-adrenoceptor subsequent signaling pathways with potential implication for cardiac fibrosis and arrhythmogenesis.

Toll-like receptor 4 is a marker of immune-mediated damage in patients with inflammatory cardiomyopathy

Purpose: Toll-like receptor 4 has been involved in the development of experimental autoimmune myocarditis. The aim of the study is to determine whether Toll-like receptor 4 plays a role in human myocarditis responsive to immunosuppression. Methods: Left ventricular endomyocardial biopsies from a subgroup of patients from the TIMIC trial were analyzed for the immunohistochemical expression of Toll-like receptor 4. In particular 18 patients (8 males,16 females, age 48.6±12.1 ys) with chronic (>6 months), virus negative (negative PCR for EV, AV, EBV, PVB19, HCV, Inf A/B, HSV1/2) inflammatory cardiomyopathy (LVEF 29.4±7.3%), responders to a 6 months treatment with prednisone and azathioprine were studied (group A). Controls were 10 left ventricular biopsies of patients with virus-negative inflammatory cardiomyopathy not responders to immunosuppression (group B) and 10 normal left ventricular surgical samples (group C). A semiquantitative evaluation of the immunoreactivity (grading from 0 to 4) was applied. Results: A focal intense positive cytoplasmic immunoreactivity was observed in cardiac myocytes of all patients in group A (grading 3.5±0.5) (panel A), with a statistically significant difference (p<0.001) compared with group B (grading 0.8±0.4) (panel B) and controls (0.2±0.4) (panel C). ![Figure][1] Conclusion: Toll-like receptor 4 is highly expressed in human immune-mediated myocarditis. It can be considered as a new marker in patient selection for immunosuppressive/immunomodulatory therapy. [1]: pending:yes

End of an Era: Reduced Severity of Tricuspid Regurgitation in Cardiac Transplant Recipients Managed with Molecular Diagnostic Testing

Purpose A well-established complication of right ventricular endomyocardial biopsy (EMB) used for the diagnosis of acute cellular rejection is damage to the tricuspid valve and subsequent tricuspid regurgitant flow. Since the advent of Molecular Diagnostic Testing (MDT) as a screening test for determining which patients require EMB, the need for EMB at our center has decreased significantly. We hypothesized that the severity of tricuspid regurgitation (TR) should therefore be reduced with greater reliance on MDT and reduced utilization of EMB. Methods and Materials 58 echocardiograms from cardiac transplant patients who survived at least two years post-transplant were reviewed by observers blinded to post-transplant rejection surveillance strategies. 30 patients were in the pre-MDT group, from 2002-2004, when only EMB was used for post-transplant rejection surveillance. 28 patients were in the MDT group, from 2008-2010, when MDT was used as a screen to determine if EMB was required. TR was graded on a scale of zero to four, with zero representing no regurgitation present on echocardiography, one representing trace, two representing mild, three representing moderate and four representing severe TR. Results Of the 30 patients evaluated from the pre-MDT group, from 2002-2004, the average TR score was 1.87. In the 28 patients evaluated after routine MDT testing was implemented, from 2008-2010, the average score was 1.30, indicating a statistically significant reduction in tricuspid regurgitation severity(p = 0.0297). There was no evidence of severe TR in the MDT patients. Conclusions Our findings demonstrate that with greater use of MDT, the severity of tricuspid regurgitation has been reduced. MDT has become an established method for monitoring immune activation and as a screen for identifying the need for EMB in low risk cardiac transplant recipients. Our findings further support the continued use of MDT as a screening test before resorting to EMB.

Connexin Expression Patterns in Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inheritable myocardial disease accounting for ventricular tachycardia and sudden death in the young and arising from areas of fibrofatty replacement of predominantly right ventricular myocardium. That some patients manifest life-threatening ventricular tachycardia in the absence of substantial myocardial replacement suggests that gap junction remodeling might be acting synergistically to ventricular remodeling to promote arrhythmogenesis. Hence, we sought to verify gap junction composition and distribution by analyzing the expression and occurrence of specific gap junction proteins (connexins [Cxs]) in patients with ARVC. Right ventricular endomyocardial biopsy specimens were taken from 16 patients with definite ARVC (age48± 16 years) and analyzed for Cx40, Cx43, and Cx45 messenger ribonucleic acid expression (relative to glyceraldehyde-3-phosphate-dehydrogenase messenger ribonucleic acid expression). The results were compared to those obtained from nondiseased donor hearts (n= 6; age 32 ± 11 years). The patients with ARVC showed a significant reduction in the messenger ribonucleic acid expression of Cx40 (p <0.0001) and Cx45 (p <0.0001) compared to that of the controls. The expression of Cx43 was similar in patients with ARVC and controls (p= 0.098). Mutations in plakophilin-2 were identified in 7 of 16 patients (25%). The Cx expression levels were comparable between the mutation carriers and noncarriers (p= NS). In conclusion, ARVC features alterations in the expression of Cxs and their distribution at cardiac intercalated discs. Apart from the deposition of extracellular matrix, the potential loss of gap junctions and shift in the composition of gap junctional Cxs in the ventricular conduction system might further contribute to the development of ventricular arrhythmias in patients with ARVC.

The invisible made visible: multi-modality imaging in the evaluation of cardiac sarcoidosis

A 34-year-old male with a radiographic ( Panel A ) and histological diagnosis of pulmonary sarcoidosis presented with symptomatic complete atrioventricular block ( Panel B ) . Right ventricular endomyocardial biopsy was negative for granulomas. Delayed gadolinium enhancement cardiac magnetic resonance imaging showed focal areas of scar in the basal and apical inferior walls …

The Results and Technique of Left Ventricular Endomyocardial Biopsy

The Results and Technique of Left Ventricular Endomyocardial Biopsy

Coronary telangiectasia associated with hypertrophic cardiomyopathy

Coronary telangiectasia (CT) is a rare congenital anomaly causing ventricular shunt and myocardial ischaemia. Its prevalence, genetic background, and impact in human hypertrophic cardiomyopathy (HCM) are unknown and were therefore investigated in this study. Among 445 patients with HCM, 195 had a coronary angiography and 124 a left ventricular endomyocardial biopsy. CT draining into the ventricular cavities was observed in 5 of 195 HCM patients (2.5%), whereas it was detected in 0.1% of 1000 consecutive subjects without congenital anomalies undergoing coronary angiography. Patients with CT-HCM underwent a total body computed tomography scan to investigate the presence of systemic vascular malformations. HCM-related MYH7, MYBPC3, TNNT2, and TPM1 genes and hereditary haemorragic telangiectasia-related endoglin and activin receptor-like kinase 1 genes were analysed. Histology, clinical profile, and outcome of CT-HCM patients were correlated with those of 22 control HCM patients. No mucocutaneous or systemic vascular malformations were detected. Gene analysis showed a MYH7 mutation in two patients, with an associated endoglin point mutation. Histology showed in the CT-HCM cohort a more pronounced myocardial fibrosis (29.8 ± 3.8%) compared with HCM controls (13 ± 2.6%), and disorganized cardiomyocytes separated by thin-walled large vessels adherent to the endocardium. Clinically, the CT-HCM cohort had a higher arrhythmic profile at diagnosis and increased incidence of implantable cardioverter defibrillator (ICD) implantations and arrhythmic deaths during a long-term follow-up. CT is detectable in 2.5% of HCM patients vs. 0.1% of the general population; it may derive from a co-existing endoglin gene mutation and cause a prominent, potentially arrhythmogenic myocardial fibrosis.