High prevalence of myocardial monoclonal antimyosin antibody uptake in patients with chronic idiopathic dilated cardiomyopathy.

Monoclonal antimyosin antibody studies were undertaken to assess the presence of myocardial uptake in patients with chronic idiopathic dilated cardiomyopathy. Three groups were studied: 17 patients with chronic (greater than 12 months) idiopathic dilated cardiomyopathy, 12 patients with a large, poorly contracting left ventricle not due to dilated cardiomyopathy (control patients) and 8 normal individuals. The patients in the cardiomyopathy and control groups showed a similar degree of clinical and functional impairment. Imaging was undertaken 48 h after antimyosin injection. The heart/lung ratio of antimyosin uptake was used to assess the results. The mean ratio in the cardiomyopathy group was 1.83 +/- 0.36 (range 1.40 to 2.80), a value significantly higher than that obtained in the control patients without cardiomyopathy (mean 1.46 +/- 0.04, range 1.38 to 1.50) or normal subjects (mean 1.46 +/- 0.13, range 1.31 to 1.6) (p less than 0.01). No difference in the ratio was noted between the normal subjects and control patients. Abnormal antimyosin uptake was seen in 12 (70%) of the 17 patients with cardiomyopathy and in only 1 (8%) of the 12 control patients. Positive monoclonal antimyosin antibody studies are highly prevalent in chronic idiopathic dilated cardiomyopathy.

Active myocardial damage without attending inflammatory response in dilated cardiomyopathy.

OBJECTIVES: This study aimed to compare indium-111 (111In)-monoclonal antimyosin antibody uptake in patients with dilated cardiomyopathy before heart transplantation with the histologic findings in the explanted hearts. BACKGROUND: A high prevalence of 111In-monoclonal antimyosin antibody uptake has been described in patients with dilated cardiomyopathy, suggesting the presence of active, ongoing myocyte damage; however, no correlation between monoclonal antimyosin antibodies and histologic findings is available in these patients. METHODS: A consecutive series of 21 patients with dilated cardiomyopathy awaiting heart transplantation were studied with monoclonal antimyosin antibodies before the operation, and the results were compared with the histologic analysis of the explanted hearts. The interval between monoclonal antimyosin antibody studies and transplantation was 1 to 90 days (mean 58 +/- 31). RESULTS: Using a semiquantitative method (heart/lung ratio), monoclonal antimyosin antibody uptake was present in 15 (71%) of 21 patients, but active myocarditis in the explanted hearts was detected in only 7. In 11 patients, intense monoclonal antimyosin antibody uptake coexisting with absent myocyte damage or cellular infiltration of explanted hearts was noted. One patient who showed preoperative monoclonal antimyosin antibody uptake underwent transplantation 11 h later, and ex vivo diffuse myocardial antimyosin uptake was detected, but active myocarditis was seen only at cardiectomy in only a small area of the heart; the rest of the myocardium showed no signs of myocyte damage. CONCLUSIONS: In dilated cardiomyopathy, monoclonal antimyosin antibody uptake cannot be equated with the presence of an inflammatory response detected in the myocardium of the explanted heart.

Spectrum of alcohol-induced myocardial damage detected by indium-111-labeled monoclonal antimyosin antibodies.

OBJECTIVES: We sought to determine the prevalence, intensity and evolving changes of myocardial damage detected by myocardial uptake of antimyosin antibodies in patients with alcohol-induced dilated cardiomyopathy, alcohol addicts attending a detoxification unit and healthy subjects with short-term alcohol consumption. BACKGROUND: Evidence of alcohol-induced myocardial damage may be provided by myocardial uptake of indium-111-labeled monoclonal antimyosin antibodies. The spectrum of such damage in patients who are heavy drinkers (> 100 g for > 10 years), with or without cardiomyopathy, and the impact of short-term alcohol ingestion on antimyosin antibody uptake have not been adequately explored. METHODS: One hundred twenty antimyosin studies were performed in 56 patients with dilated cardiomyopathy (group I), 15 alcohol addicts attending a detoxification unit (group II) and 6 volunteers for short-term alcohol ingestion (group III). Estimation of antibody uptake was calculated through a heart/lung ratio (HLR) (normal < 1.55). RESULTS: The 56 patients in group I (54 men, 2 women; mean [+/-SD] age 46 +/- 11 years) had consumed 123 +/- 60 g/day of alcohol for 21 +/- 9 years, for a cumulative intake of 914 +/- 478 kg. Mean duration of symptoms was 46 +/- 49 months. Mean left ventricular end-diastolic diameter was 71 +/- 10 mm, and mean ejection fraction was 28 +/- 12%. No differences in New York Heart Association functional class, ventricular size or ejection fraction were noted between 28 active and 28 past consumers, except for the prevalence and intensity of antibody uptake (75% vs. 32%, p < 0.001) and HLR (1.75 +/- 0.26 vs. 1.49 +/- 0.17, p = 0.0001). In 19 patients in the active group restudied after alcohol withdrawal, antibody uptake decreased (from 1.76 +/- 0.17 to 1.55 +/- 0.19, p < 0.001), and ejection fraction improved (from 30 +/- 12% to 43 +/- 16%, (p < 0.001). No changes occurred in the 15 past consumers restudied. The 15 male patients in group II (mean age 36 +/- 4 years) had consumed 156 +/- 59 g/day for 17 +/- 5 years, for a cumulative alcohol intake of 978 +/- 537 kg, an amount similar to that in patients in group I, but antimyosin antibody uptake was detected in only 3 (20%) of 15 patients. None of six group III subjects developed antibody uptake after short-term ethanol ingestion. Despite the small sample size, the power to detect clinically relevant differences in most variables that did not reach statistical significance was amply sufficient. CONCLUSIONS: In alcohol-induced dilated cardiomyopathy, alcohol withdrawal is associated with the reduction or disappearance of myocardial damage and improvement of function. The difference in prevalence of antimyosin antibody uptake in patients with and without cardiac disease who consume similar amounts of alcohol suggests the presence of those with different myocardial susceptibilities to alcohol. Short-term ethanol ingestion in healthy subjects does not induce detectable uptake of antimyosin antibodies.

Indium-111 antimyosin scintigraphy to assess myocardial damage in patients with suspected myocarditis and cardiac rejection.

Indium-111 antimyosin scans were used to assess myocardial damage in patients with suspected myocarditis and cardiac transplant rejection. The calculation of a myocardium to lung ratio (AM index) to quantify antimyosin uptake was performed. AM index in normal subjects (n = 8) at 48 hr postinjection was 1.46 +/- 0.04. In patients with suspected myocarditis (16 studies in 13 patients), AM index was 2.0 +/- 0.5 (p less than 0.001); suggesting a considerable incidence of ongoing cell damage in this group, despite the small proportion of positive right ventricular endomyocardial biopsy (RVbx) (4/13). In patients studied after cardiac transplantation (37 studies in 17 patients), AM indexes correlated with RVbx. In patients with RVbx proven rejection (n = 14), AM index was 1.87 +/- 0.19 (p less than 0.001). In patients with RVbx showing infiltrates but not myocyte damage (n = 13), AM index was 1.80 +/- 0.27 (p = 0.02). In patients with normal RVbx (n = 10), AM index was 1.56 +/- 0.17 (p = NS versus controls; p = 0.001 versus those with positive RVbx). Calculated AM indexes correlated with graded visual analysis of the scans (r = 0.823; p = 0.001). Antimyosin scans are an appropriate method to assess myocardial damage in patients with suspected myocarditis and cardiac rejection.

Epidemiologic evidence of transmission of donor-related bacterial infection through a transplanted heart.

This study describes a patient who had fulminant infectious myocarditis as a result of methicillin-resistant Staphylococcus aureus after receiving a heart transplant from an infected donor. There was complete concordance of typing results between donor and recipient strains that were different from the 20 isolates with which they were compared. Molecular epidemiologic study provided compelling evidence that a transplanted organ can transmit a bacterial infection from the donor to the recipient.

Reversal of dilated cardiomyopathy after chronic tricyclic antidepressant drug withdrawal.

Two patients referred for heart transplantation for dilated cardiomyopathy on chronic tricyclic antidepressant treatment are described. Echocardiographic normalization of left ventricular diameters and function were evidenced after drug withdrawal, suggesting drug-induced toxic myocardial disease. The possibility of functional improvement after tricyclic antidepressant drug withdrawal should be kept in mind before including patients with dilated cardiomyopathy in a heart transplantation program.

Dopamine treatment of locally procured donor hearts: relevance on postoperative cardiac histology and function.

UNLABELLED: Administration of catecholamines can lead to myocyte damage. Dopamine treatment is often used in potential cardiac donors to attain hemodynamic stability. Donor hearts exposed to dopamine are rejected or selected for transplantation without clearly defined criteria. A prospective study was undertaken to analyze the clinical relevance of dopamine-induced myocardial lesions in 25 hearts (21 male, 4 female; 15-40 years, mean: 26 +/- 7) that were later used for transplantation. Donors were divided into those who had received dopamine and those who had not. Dopamine doses ranged from 2-12.5 micrograms/kg/min (mean: 6.3 +/- 3). Time of administration was 3-26 hours (mean: 16 +/- 8). Use of dopamine was unrelated to donor electrocardiographic findings, intra- or postoperative death, or difficulty coming off by-pass. Postoperatively, filling pressures were similar in both groups of patients at 2 and 10 days postoperatively. Left ventricular ejection fraction was similar in the two groups. Dopamine requirements were significantly higher in the dopamine-treated hearts (P = 0.05). Histologic findings at first biopsy revealed infiltration and cell damage in a similar proportion of patients in both groups. IN CONCLUSION: donor hearts exposed to dopamine can be accepted for transplantation if doses ranging from 2-12.5 micrograms/kg/min have been administered up to 24 hours.

Evaluation of patients with suspected acute coronary syndromes in the emergency department.

Patients complaining of chest pain (CP) who visit the emergency department (ED) represent the second cause of consultation in this department, and 20-30% of hospital admissions for medical reasons. These patients form a somewhat heterogeneous group with many different aetiologies and degrees of severity. In this setting, the clinical objectives include the prompt identification of patients with acute coronary syndromes (ACSs), the prompt evaluation of the immediate risk (i.e., initial risk stratification) of cardiovascular complications in order to tailor the treatment for each individual patient and to make the best use of hospital resources, and the prompt identification of patients with other potentially severe diseases. The diagnosis of ACS in patients coming to the ED for CP or any equivalent angina is one of the most difficult diagnostic challenges facing physicians in the ED. The correct diagnosis and risk stratification of these patients has clinical consequences, as well as very important legal and economic implications. The only methodology with a clear clinical impact on diagnosis, risk stratification and initial management is clinical evaluation based on data obtained by questioning the patient, carrying out a physical examination, and interpreting the results of a standard 12-lead electrocardiogram (ECG). Nevertheless, its combined diagnostic efficiency for ACS is imperfect and additional strategies are emerging which include serial ECG, the detection of serum biochemical markers of myocardial necrosis, exercise testing, and radionuclide myocardial perfusion imaging.

[Percutaneous coronary transluminal angioplasty in a heart transplant recipient]. / Angioplastia coronaria transluminal percutánea en un receptor de trasplante de corazón.

A 46-year-old female, who underwent an orthotopic heart transplantation 5 years ago, presented an occlusive coronary artery disease with severe stenosis of the left anterior descending artery and a large septal perforator. An isonitrile scintigraphy showed a decreased uptake involving the anterior and inferior segments of the left ventricle. Percutaneous transluminal coronary angioplasty was successfully performed in both lesions. Three months after dilatation, improvement of the uptake in both myocardial segments was detected. The results of the percutaneous transluminal coronary angioplasty published in the literature are reviewed.

[The diagnosis of rejection activity in the heart transplant by monoclonal antimyosin antibodies]. / Diagnóstico de la actividad de rechazo en el trasplante cardíaco mediante anticuerpos monoclonales antimiosina.

A novel noninvasive sensitive mean to detect cardiac rejection is described: myocardial uptake of 111In-labeled monoclonal antimyosin antibodies (MAA). All patients showing rejection at cardiac biopsy disclosed positive MAA studies. However, a large percentage of positive studies in the presence of negative biopsies were detected. This discrepancy can be ascribed to a false-negative biopsy result. During the first year posttrasplantation MAA studies are useful to predict severe rejection-related complications, but due to high sensitivity of MAA, treatment for rejection in this period must be based on biopsies, as criterium to treat for rejection on the basis of MAA scans would lead to excessive immunosuppression. After the first year of transplantation, individual patient management can ben implemented on the basis of risk stratification using MAA scans: Negative MAA scans entail an almost nil probability of detecting rejection during long-term follow-up (low-risk group), whereas positive MAA scans imply a probability of detecting near 1 episode of rejection and requirement for treatment per year. In summary, at our institution biopsies are avoided as from the first year after transplantation; after such period, MAA scans allow risk stratification and treatment for rejection based on the results of MAA scans in individual patients.

[FDG-PET in hepatocellular carcinoma. Based on one case]. / PET-FDG en el hepatocarcinoma. A propósito de un caso.

We present a case of a 73 year old man, who lost 12 kg of weight in one month, had abdominal pain and progressive hepatic failure. A MRI and liver ultrasound were performed and, with the patient's symptoms, hepatocellular carcinoma Vs metastatic liver was suspected. A PET-FDG was performed and the images showed hepatomegaly and splenomegaly, without other findings of interest. FDG distribution in the liver was homogeneous. The patient was diagnosed of hepatocellular carcinoma after liver biopsy. FDG-PET detects only 50 % to 70 % of hepatocellular carcinomas due to varying degrees of activity of the enzyme glucose-6-phosphatase in these tumors. This paper reviews the literature on this type of situations.