Assessment of edema using STIR+ via 3D cardiovascular magnetic resonance imaging in patients with suspected myocarditis.

OBJECTIVE: To evaluate three-dimensional T2-weighted fast spin echo triple inversion recovery sequences (STIR+) for the diagnosis of myocardial edema in patients with suspected early myocarditis after respiratory or gastrointestinal tract viral infection and at follow-up. MATERIALS AND METHODS: We prospectively examined 28 patients with suspected myocarditis and 37 controls matched for gender and age. An ECG-triggered STIR+ was used to cover the entire left ventricle in short-axis images with 10-mm slice thickness and no interslice gap. The global signal intensity ratio (heart muscle in relation to skeletal muscle) was calculated (global STIR+ ratio) to evaluate edema. All patients had repeat examinations at follow-up (mean interval 4.9 months, 1-12 months). RESULTS: The mean global STIR+ ratio was 2.15 ± 0.4 in the initial examination of patients as compared to 1.78 ± 0.3 in controls (p < 0.0001) and 1.89 ± 0.3 in patients at follow-up (p = 0.0001 vs. first visit). Left ventricular ejection fraction did not differ between patients and controls at baseline and at follow-up. CONCLUSION: We could identify a significantly higher global STIR+ ratio in patients with suspected myocarditis compared to controls, and a dynamic change during follow-up. The global STIR+ ratio may, therefore, be useful for the diagnosis of myocarditis and should be further explored.

Patients with exercise-associated ventricular ectopy present evidence of myocarditis.

BACKGROUND: The origin and clinical relevance of exercise-induced premature ventricular beats (PVBs) in patients without coronary heart disease or cardiomyopathies is unknown. Cardiovascular magnetic resonance enables us to non-invasively assess myocardial scarring and oedema. The purpose of our study was to discover any evidence of myocardial anomalies in patients with exercise-induced ventricular premature beats. METHODS: We examined 162 consecutive patients presenting palpitations and documented exercise-induced premature ventricular beats (PVBs) but no history or evidence of structural heart disease. Results were compared with 70 controls matched for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained as well as LV function and dimensions. RESULTS: Structural anomalies in the myocardium and/or pericardium were present in 85 % of patients with exercise-induced PVBs. We observed a significant difference between patients with PVBs and controls in late gadolinium enhancement, that is 68 % presented subepicardial or midmyocardial lesions upon enhancement, whereas only 9 % of the controls did so (p < 0.0001). More patients presented pericardial enhancement (35 %) or pericardial thickening (27 %) compared to controls (21 % and 13 %, p < 0.0001). Myocardial oedema was present in 37 % of the patients and in only one control, p < 0.0001. Left ventricular ejection fraction did not differ between patients and controls (63.1 ± 7.9 vs. 64.7 ± 7.0, p = 0.13). CONCLUSIONS: The majority of patients with exercise-associated premature ventricular beats present evidence of myocardial disease consistent with acute or previous myocarditis or myopericarditis.

Diagnosis of viral myocarditis by cardiac magnetic resonance and viral genome detection in peripheral blood.

In patients with acute myocarditis, viral genome can be detected in plasma and peripheral leukocytes. Its relationship with active myocardial inflammation, however, is not well understood. Myocardial edema as a feature of inflammation and myocardial necrosis or fibrosis can be frequently observed in patients with acute myocarditis by cardiovascular magnetic resonance (CMR). We assessed the association of viral genome presence in peripheral blood samples with myocardial edema and irreversible injury. We examined consecutive patients with clinically suspected myocarditis after an episode of viral illness. State-of-the-art methods were used for detecting myocardial edema and irreversible injury using CMR and viral genome applying reverse transcribed, nested polymerase chain reaction in peripheral blood samples. The specificity of viral amplification products was confirmed by automatic DNA sequencing. Of a total of 55 patients (53.5 ± 15.6 years), 21 were positive for viral genome in peripheral leukocytes. Interestingly, 18 (86%) of these patients also showed global myocardial edema, as compared to only 7/34 (21%) without PCR evidence for viral genome. The overall agreement between CMR criteria for edema and viral PCR was 84%. In contrast, there was no significant relationship of viral genome presence with myocardial necrosis or scars. In patients with clinically suspected myocarditis, myocardial edema but not irreversible myocardial injury is associated with the presence of viral genome in peripheral blood.

Evidence of myocardial edema in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Nonischemic dilated cardiomyopathy (DCM) is associated with high mortality and morbidity. Cardiovascular magnetic resonance allows for the noninvasive assessment of function, morphology, and myocardial edema. Activation of inflammatory pathways may play an important role in the etiology of chronic DCM and may also be involved in the disease progression. HYPOTHESIS: The purpose of our study was to assess the incidence of myocardial edema as a marker for myocardial inflammation in patients with nonischemic DCM. METHODS: We examined 31 consecutive patients ( mean age, 57 ± 12 years) with idiopathic DCM. Results were compared with 39 controls matched for gender and age (mean age, 53 ± 13 years). Parameters of left ventricular function and volumes, and electrocardiogram-triggered, T2-weighted, fast spin echo triple inversion recovery sequences were applied in all patients and controls. Variables between patients and controls were compared using t tests for quantitative and χ2 tests for categorical variables. RESULTS: Ejection fraction (EF) was 40.3 ± 7.8% in patients and 62.6 ± 5.0% in controls (P < 0.0001). In T2-weighted images, patients with DCM had a significantly higher normalized global signal intensity ratio compared to controls (2.2 ± 0.6 and 1.8 ± 0.3, respectively, P = 0.0006), consistent with global myocardial edema. There was a significant but moderate negative correlation between signal intensity ratio in T2-weighted images and EF (-0.39, P < 0.001). CONCLUSIONS: Evidence shows that myocardial edema is associated with idiopathic nonischemic DCM. Further studies are needed to assess the clinical and prognostic impact of these findings.

Mitral valve reconstruction in a patient with Libman-Sacks endocarditis: a case report.

A symptomatic young woman with newly diagnosed systemic lupus erythematosus and secondary antiphospholipid syndrome with elevated anticardiolipin antibodies presented with small nodules on both leaflets of the mitral valve and with a consecutive high-grade mitral regurgitation, as diagnosed by echocardiography. In consideration of the preoperative and intraoperative findings, and the patient's low age, a mitral valve repair with removal of the leaflet vegetations and a ring annuloplasty were performed.

Diagnosis of early myocarditis after respiratory or gastrointestinal tract viral infection: insights from cardiovascular magnetic resonance.

BACKGROUND: The diagnosis of myocarditis continues to be a challenging task in clinical practice. The purpose of our study was to investigate cardiovascular magnetic resonance imaging in the diagnostic workup of ambulatory patients with the suspicion of early myocarditis after respiratory or gastrointestinal tract viral infection. The need for accurate diagnosis of early myocarditis arises from the low diagnostic accuracy of routine clinical tests. METHODS: We examined 67 consecutive patients with symptoms of weakness, palpitations, and fatigue after respiratory or gastrointestinal tract infection. We compared these patients to 31 controls. ECG-triggered, T2-weighted, fast-spin-echo triple inversion recovery sequences and delayed enhancement imaging were obtained in all patients, as well as functional parameters of left ventricular function and dimensions. In addition, in 25 patients and 10 controls, ECG-triggered, T1-weighted, multi-slice spin-echo images were obtained in axial orientation. RESULTS: We found a significant difference between patients with suspected myocarditis and controls in T2-global myocardial signal intensity. In addition, the ratio of global myocardial signal intensity/muscle signal intensity was 2.3 ± 0.4 in patients and 1.8 ± 0.3 in controls, which was highly significant (p < 0.001). In 23 patients, a pathological late enhancement pattern was seen, but only in one of the controls. There was no significant difference in T1-signal parameters. CONCLUSION: Cardiovascular magnetic resonance technique is able to detect early myocardial involvement after respiratory or gastrointestinal tract infection.

Non-invasive imaging in the diagnosis of acute viral myocarditis.

Autopsy series of consecutive cases have demonstrated an incidence of myocarditis at approximately 1-10%; on the contrary, myocarditis is seriously underdiagnosed clinically. In a traditional view, the gold standard has been myocardial biopsy. However, it is generally specific but invasive and less sensitive, mostly because of the focal nature of the disease. Thus, non-invasive approaches to detect myocarditis are necessary. The traditional diagnostic tools are electrocardiography, laboratory values, especially troponin T or I, creatine kinase and echocardiography. For a long period, nuclear technique with indium-111 antimyosin antibody has been used as a diagnostic approach. In the last years, the use of this technique has declined because of radiation exposure and 48-h delay in obtaining imaging after injection to prevent blood pool effect. Thus, a non-invasive diagnostic approach without radiation and online image availability has been awaited. Cardiac magnetic resonance imaging has these promising characteristics. With this technique, it is possible to analyse inflammation, oedema and necrosis in addition to functional parameters such as left ventricular function, regional wall motion and dimensions. Thus, cardiovascular magnetic resonance imaging has emerged as the most important imaging tool in the diagnostic procedure and the review focus on this field. But there are also advances in echocardiography and computer tomography, which are described in detail.

Cardiac involvement after respiratory tract viral infection--detection by cardiac magnetic resonance.

OBJECTIVE: The purpose of our study was to investigate whether cardiovascular magnetic resonance imaging can detect early myocardial tissue edema as a first step in the development of myocarditis. METHODS: We examined 36 consecutive patients who were presented with symptoms of fatigue, weakness, and/or palpitations after respiratory tract infection but normal left ventricular function and compared these patients with 21 consecutive controls without acute symptoms. Electrocardiogram-triggered, T2-weighted, fast spin echo triple-inversion recovery sequences were performed in all patients. RESULTS: We found a significant difference between patients with suspected myocarditis and controls in global myocardial signal intensity. The ratio of global myocardial signal intensity/muscle signal intensity was 2.4 +/- 0.3 in patients and 1.9 +/- 0.3 in controls, which was highly significant (P < 0.001). CONCLUSIONS: Patients with symptoms of fatigue, weakness, and/or palpitations after respiratory tract infection showed an elevated signal intensity of the myocardium, indicating edematous tissue, which may be the first step in the development of myocarditis.

Tricuspidization of the quadricuspid aortic valve.

Quadricuspid aortic valves represent an uncommon congenital abnormality. Patients may have aortic regurgitation and become symptomatic at a younger age than patients with other types of aortic valve anatomy. We report 3 patients who underwent successful repair by tricuspidization of the aortic valve.

Coronary vasoregulation in patients with various risk factors in response to cold pressor testing: contrasting myocardial blood flow responses to short- and long-term vitamin C administration.

OBJECTIVES: We sought to determine whether abnormal myocardial blood flow (MBF) responses to the cold pressor test (CPT) in patients with various risk factors may involve different mechanisms that could lead to varying responses of short- and long-term administration of antioxidants. BACKGROUND: There is a growing body of evidence that increased vascular production of reactive oxygen species markedly reduces the bioavailability of endothelium-derived nitric oxide, leading to impaired vasodilator function. It is unknown whether increased oxidative stress is the prevalent mechanism underlying endothelial dysfunction in patients with different coronary risk factors. METHODS: Fifty patients with normal coronary angiograms were studied. The MBF responses to CPT was determined by means of positron emission tomography before and after intravenous infusion of 3 g vitamin C or saline (placebo), as well as after 3 months and 2 years of 2 g vitamin C or placebo supplementation daily. RESULTS: In hypertensive patients, the change in MBF (DeltaMBF) was not modified significantly by short-term vitamin C administration challenges (0.20 +/- 0.20 ml/g/min; p = NS) but was significantly increased after three months and two years of treatment with vitamin C versus baseline (0.58 +/- 0.27 and 0.63 +/- 0.17 vs. 0.14 +/- 0.18 ml/g/min; both p < or = 0.001). In smokers, DeltaMBF in response to CPT was significantly increased after short-term vitamin C infusion and long-term vitamin C treatment (0.52 +/- 0.10, 0.54 +/- 0.13, 0.50 +/- 0.07 vs. -0.08 +/- 0.10 ml/g/min; all p < or = 0.001). In hypercholesterolemic patients, no improvement in DeltaMBF during CPT was observed after short- and long-term vitamin C treatment (0.05 +/- 0.14, 0.08 +/- 0.18, 0.02 +/- 0.19 vs. 0.08 +/- 0.16 ml/g/min; p = NS). The CPT-induced DeltaMBF in hypertensive patients and smokers after follow-up was significant as compared with placebo and control subjects (p < or = 0.001). CONCLUSIONS: The present study revealed marked heterogeneous responses in MBF changes to short- and long-term vitamin C treatment in patients with various risk factors, which highlights the quite complex nature underlying abnormal coronary vasomotion.