Myocardial inflammation in Duchenne Muscular Dystrophy as a precipitating factor for heart failure: a prospective study.

BACKGROUND: In patients with Duchenne Muscular Dystrophy (DMD), the absent or diminished dystrophin leads to progressive skeletal muscle and heart failure. We evaluated the role of myocardial inflammation as a precipitating factor in the development of heart failure in DMD. METHODS: 20 DMD patients (aged 15-18 yrs) and 20 age-matched healthy volunteers were studied and followed-up for 2 years. Evaluation of myocarditis with cardiovascular magnetic resonance imaging (CMR) was performed using STIR T2-weighted (T2W), T1-weighted (T1W) before and after contrast media and late enhanced images (LGE). Left ventricular volumes and ejection fraction were also calculated. Myocardial biopsy was performed in patients with positive CMR and immunohistologic and polymerase chain reaction (PCR) analysis was employed. RESULTS: In DMD patients, left ventricular end-diastolic volume (LVEDV) was not different compared to controls. Left ventricular end-systolic volume (LVESV) was higher (45.1 +/- 6.6 vs. 37.3 +/- 3.8 ml, p < 0.001) and left ventricular ejection fraction (LVEF) was lower (53.9 +/- 2.1 vs. 63 +/- 2.4%, p < 0.001). T2 heart/skeletal muscle ratio and early T1 ratio values in DMD patients presented no difference compared to controls. LGE areas were identified in six DMD patients. In four of them with CMR evidence of myocarditis, myocardial biopsy was performed. Active myocarditis was identified in one and healing myocarditis in three using immunohistology. All six patients with CMR evidence of myocarditis had a rapid deterioration of left ventricular function during the next year. CONCLUSIONS: DMD patients with myocardial inflammation documented by CMR had a rigorous progression to heart failure.

Outcomes after a left anterior descending artery endarterectomy in advanced coronary artery disease.

BACKGROUND: Coronary endarterectomy albeit infrequently utilized remains a pivotal treatment modality for advanced atherosclerotic heart disease. Benefits of coronary endarterectomy are explored in terms of better mid-term survival, freedom of major adverse cardiac and cerebrovascular events and improved left ventricular ejection fraction. METHODS: 50 patients with coronary artery disease including extensive diffuse LAD disease underwent a left anterior descending artery endarterectomy with coronary by-pass grafting and left internal mammary artery as conduit between 2006 and 2014. Prospective evaluation was performed on an outpatient basis with physical examination, echo recordings of ejection fraction and LAD flow reserve for 24 up to 60months. RESULTS: Study group was constituted by a male to female ratio 4:1 and mean age 62.4years old. Pre-operative characteristics included patients with age<60years old and gensini score>60 in 42.1% while patients with age>60years old had gensini score (21-60) in 63.4%. Furthermore, males were affected more severely by atherosclerosis than females. Postoperative anterior wall contractility of left ventricle was improved (56% pre-op vs. 66% post-op) and hypokinesis reduced (34% pre-op vs. 24% post-op). No deaths were recorded for a mean follow-up of 48months. Also, MACCE were recorded in 8% patients. Post-operative LAD flow reserve was normal in 66% and reduced in 33% of cases. Finally, gensini score preoperatively affects mid-term flow reserve postoperatively (p<0.05). CONCLUSION: Coronary endarterectomy presents a viable modality that preserves myocardial function and restores LAD flow in patients with diffuse atherosclerotic LAD. Also postoperative adverse effects were minimal while mid-term flow reserve was affected by preoperative factors.

Myocardial inflammation in autoimmune diseases: investigation by cardiovascular magnetic resonance and endomyocardial biopsy.

INTRODUCTION: Myocardial inflammation often coexists with different types of autoimmune diseases. Our aim was to investigate the presence of myocarditis in these patients by Cardiovascular Magnetic Resonance (CMR) and endomyocardial biopsy. PATIENTS-METHODS: Twenty patients, aged 20-55 yrs with autoimmune diseases and cardiac symptoms (3 with Takayasu's arteritis, 3 with systemic lupus erythematosus, 5 with rheumatoid arthritis, 7 with autoimmune thyroid disease and 2 with systemic sclerosis) and 20 patients with the same autoimmune diseases but without cardiac symptoms (controls) were studied. The presence of myocarditis and LV function were evaluated by CMR. Myocarditis was documented using T2-weighted (T2-W), T1-weighted (T1-W) before and after contrast media injection and late enhanced images. In 10 patients (positive for myocarditis by CMR with either low LVEF or recent increase in troponin), endomyocardial biopsy was also performed. Myocardial specimens were evaluated by histology and polymerase chain reaction techniques (PCR). RESULTS: Myocarditis was identified in 18/20 patients by CMR. In the T2-W images the signal ratio of myocardium to skeletal muscle was 1.89+/-0.25 (control values 1.57+/-0.13, p<0.05). From the T1-W images the relative myocardial enhancement was 11.31+/-11.18 (control values 3.09+/-0.05, p<0.05). Epicardial late gadolinium enhanced areas were identified in 18/20. In myocardial specimens, histology revealed inflammation in 5/10 (50%) and PCR documented viral or microbial genomes in 8/10 (80%). Positive histology and PCR were in agreement with 50% and 80% of positive CMR examinations, respectively. Herpes virus was identified in 3/10, Adeno in 1/10, Coxsackie B6 in 1/10, echo in 1/10, Parvo-B19 in 3/10, CMV in 1/10 and Chlamydia trachomatis in 8/10. CONCLUSIONS: Myocardial inflammation is a common finding in patients with autoimmune diseases and cardiac symptoms. The diagnosis can be confirmed by CMR, which is a noninvasive and reliable tool for the investigation of these patients.