Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging.

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.

Diabetic cardiomyopathy: ongoing controversies in 2012.

Diabetic cardiomyopathy is a controversial clinical entity that in its initial state is usually characterized by left ventricular diastolic dysfunction in patients with diabetes mellitus that cannot be explained by coronary artery disease, hypertension, or any other known cardiac disease. It was reported in up to 52-60% of well-controlled type-II diabetic subjects, but more recent studies, using standardized tissue Doppler criteria and more strict patient selection, revealed a much lower prevalence. The pathological substrate is myocardial damage, left ventricular hypertrophy, interstitial fibrosis, structural and functional changes of the small coronary vessels, metabolic disturbance, and autonomic cardiac neuropathy. Hyperglycemia causes myocardial necrosis and fibrosis, as well as the increase of myocardial free radicals and oxidants, which decrease nitric oxide levels, worsen the endothelial function, and induce myocardial inflammation. Insulin resistance with hyperinsulinemia and decreased insulin sensitivity may also contribute to the left ventricular hypertrophy. Clinical manifestations of diabetic cardiomyopathy may include dyspnea, arrhythmias, atypical chest pain, and dizziness. Currently, there is no specific treatment of diabetic cardiomyopathy that targets its pathophysiological substrate, but various therapeutic options are discussed that include improving diabetic control with both diet and drugs (metformin and thiazolidinediones), the use of ACE inhibitors, beta blockers, and calcium channel blockers. Daily physical activity and a reduction in body mass index may improve glucose homeostasis by reducing the glucose/insulin ratio and the increase of both insulin sensitivity and glucose oxidation by the skeletal and cardiac muscles.

[Diagnosis of pericardial cysts: significance of cardiac magnetic resonance and literature review].

Pericardial cysts are uncommon and caused by an incomplete coalescence of fetal lacunae forming the pericardium. The paper presents two cases of pericardial cyst and literature review. The first is a case of a female patient with progressive dispnoa and spherical mass located in the right cardiophrenic angle on a chest x-ray. A pericardial cyst with low signal intensity was noted on T1w, high signal intensity on T2w in TSE (turbo spin echo) sequence on magnetic resonance images (MRI) which was suggestive of serous content. The patient underwent pericardial puncture and was thereafter free of symptoms. Histologic study of the cyst confirmed hydatid cyst diagnosis. Another patient is with echocardiographic evidence of cystic formation which was confirmed on MRI, with high signal intensity on SSFP (steady state free precession) sequence. The cyst was without septa and without communication with pericardial space. Since there were no significant hemodynamic changes, the patient is on regular follow up.

Cardiac imaging in rheumatic diseases.

The majority of the imaging techniques in cardiology could be applied in rheumatic diseases (RDs), such as echocardiography, single-photon emission computed tomography (SPECT), radionuclide ventriculography, angiography, cardiovascular MRI and CT. Inflammatory pericardial involvement is the most common cardiac manifestation in various forms of RD. Echocardiography is the gold standard for diagnosis of pericardial abnormalities, demonstrating location and amount of pericardial effusion. Cardiac MRI and CT can be used to assess the features of pericardial effusions and pericardial structures. In patients with valvular heart disease in RD, transoesophageal echocardiography is a superior method and offers reliable information about valve morphology, the severity of the disease and left ventricular (LV) function. In addition, cardiac MRI is a valuable tool for the evaluation of valvular stenosis and regurgitation severity. Myocardial involvement in RD is demonstrated by abnormalities in LV size and function, indicating myocardial inflammation. In these patients Doppler echocardiography and myocardial tissue imaging can provide essential diagnostic information. Both LV angiography and cardiac MRI can provide reliable information on LV size, function and mass. In patients with coronary disease associated with RD, LV ejection fraction and ventricular wall motion can be assessed by echocardiography, radionuclide ventriculography, gated SPECT and MRI. Three-dimensional (3D) echocardiography is considered superior to 2D echocardiographic techniques. Stress echocardiography is the most used method for detection of myocardial ischaemia. The only accurate visualization of the coronary arteries is by selective coronary arteriography, which remains the gold standard. Although new non-invasive techniques have been developed, including CT and MRI angiography, some limitations apply.

Cardiac arrhythmias and conduction disturbances in autoimmune rheumatic diseases.

Rhythm and conduction disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in autoimmune rheumatic diseases (ARDs). In patients with rheumatoid arthritis (RA), a major cause of SCD is atherosclerotic coronary artery disease, leading to acute coronary syndrome and ventricular arrhythmias. In systemic lupus erythematosus (SLE), sinus tachycardia, atrial fibrillation and atrial ectopic beats are the major cardiac arrhythmias. In some cases, sinus tachycardia may be the only manifestation of cardiac involvement. The most frequent cardiac rhythm disturbances in systemic sclerosis (SSc) are premature ventricular contractions (PVCs), often appearing as monomorphic, single PVCs, or rarely as bigeminy, trigeminy or pairs. Transient atrial fibrillation, flutter or paroxysmal supraventricular tachycardia are also described in 20-30% of SSc patients. Non-sustained ventricular tachycardia was described in 7-13%, while SCD is reported in 5-21% of unselected patients with SSc. The conduction disorders are more frequent in ARD than the cardiac arrhythmias. In RA, infiltration of the atrioventricular (AV) node can cause right bundle branch block in 35% of patients. AV block is rare in RA, and is usually complete. In SLE small vessel vasculitis, the infiltration of the sinus or AV nodes, or active myocarditis can lead to first-degree AV block in 34-70% of patients. In contrast to RA, conduction abnormalities may regress when the underlying disease is controlled. In neonatal lupus, 3% of infants whose mothers are antibody positive develop complete heart block. Conduction disturbances in SSc are due to fibrosis of sinoatrial node, presenting as abnormal ECG, bundle and fascicular blocks and occur in 25-75% of patients.

Acute and 3-month treatment effects of candesartan cilexetil on hemodynamics, neurohormones, and clinical symptoms in patients with congestive heart failure.

BACKGROUND: This study evaluated the short-term and long-term effects of the angiotensin II type 1 receptor antagonist candesartan cilexetil on hemodynamics, neurohormones, and clinical symptoms in patients with congestive heart failure (CHF). METHODS: In this multicenter, double-blind, parallel-group study, 218 patients with CHF (New York Heart Association class II or III) with impaired left ventricular function (ejection fraction < or =40%) and pulmonary capillary wedge pressure > or =13 mm Hg were randomly assigned to 12 weeks of treatment with placebo (n = 44) or candesartan cilexetil (2 mg [n = 45], 4 mg [n = 46], 8 mg [n = 39], or 16 mg [n = 44]) once daily after a 2-week placebo run-in period. Hemodynamic measurements were performed by right heart catheterization over a 24-hour period after single (day 1) and repeated (3-month) treatment with the study drug. RESULTS: On regression analysis of the time-response curves, single and multiple doses of candesartan cilexetil produced sustained, significant, and dose-dependent reductions in pulmonary capillary wedge pressure (short-term effect P =.036, long-term effect P =.035) and mean pulmonary arterial pressure (short-term effect P =.031, long-term effect P =.042). Systemic vascular resistance showed a trend toward decreasing with dose on short-term and long-term treatments. No consistent changes were seen in cardiac index. Compensatory increases in plasma renin activity and angiotensin II levels with decreases in aldosterone and atrial natriuretic peptide were dose-dependent and significant. Candesartan cilexetil improved clinical symptoms, stabilized patient New York Heart Association status compared with placebo, and was judged to be an efficacious treatment by the investigators. More patients receiving placebo stopped the trial prematurely because of an adverse event than in any candesartan cilexetil group, and there was no excess of deaths in any treatment group. Candesartan was safe and well tolerated at all dosages. CONCLUSIONS: Candesartan cilexetil demonstrated significant short-term and long-term improvements in hemodynamic, neurohormonal, and symptomatic status and was well tolerated in patients with CHF.

Arrhythmias in acute pericarditis. An endomyocardial biopsy study.

It is still controversial whether the arrhythmias in acute pericarditis are of myocardial or pericardial origin. The aim of the present study was to investigate the occurrence of arrhythmias and conduction disorders in patients with acute pericarditis with no endomyocardial biopsy evidence of myocarditis (group 1: 40 patients, 65% males, mean age 45.6 +/- 15.7 years, mean heart rate [HR] 98.7 +/- 22.2 beats per minute) in comparison to endomyocardial biopsy proven acute myocarditis/perimyocarditis (group 2: 10 patients, 3/10 with perimyocarditis, 70% males, mean age 46.1 +/- 15.8 years, mean heart rate 76.7 +/- 33.1 beats per minute). At the initial assessment all patients underwent comprehensive clinical work-up including echocardiography, cardiac catheterization, and endomyocardial biopsy. In all patients biventricular endomyocardial biopsy was performed using standard femoral approach and Schikumed 7 F or 8 F bioptomes. Tissue samples were stained by H & E, v. Gieson and independently reviewed by two cardiac pathologists. In addition immunohistochemistry and immunocytochemistry were performed, and only patients fulfilling Dallas and World Heart Federation criteria were selected for group 2. Comparative analysis of electrocardiograms and 24-hour Holter recordings at initial presentation revealed in group 1 vs group 2 significantly less frequent paroxysmal supraventricular tachyarrhythmias (5% vs 40%), and ventricular fibrillation (0 vs 20%), in contrast to atrial fibrillation that occurred more often (20% vs 0) (all p < 0.05). Furthermore, in the group 2 one patient died due to VF and two patients underwent ICD implantation. Low voltage (40% vs 30%) and ST/T wave changes (47.5% vs 30%), as well as the incidence of the II degree AV block (5% vs 0) and complete AV block (2.5% vs 10%) were not significantly different between the groups. In conclusion, patients with pericarditis and no endomyocardial biopsy indications of myocarditis had significantly less often life threatening rhythm disorders in contrast to patients with endomyocardial biopsy proven acute myocarditis/perimyocarditis. On the contrary, incidence of transitory atrial fibrillation was higher in acute pericarditis, than in myocarditis.

Flexible percutaneous pericardioscopy: inherent drawbacks and recent advances.

Pericardioscopy enables endoscopic inspection and aimed biopsy of the parietal and visceral pericardium. To elucidate possible technical modifications contributing to the feasibility, diagnostic value and safety of the procedure, pericardioscopy with an Olympus HYF-1T flexible endoscope was performed in 32 patients (53.1% males, mean age 46.2 +/- 13.1 years) with pericardial effusions. In all patients, the initial step of the procedure was subxiphoid fluoroscopically controlled pericardiocentesis and drainage of the pericardial effusion. An Olympus FB-41ST biopsy forceps was applied for endoscopically guided pericardial biopsies. Standard sampling was used in 22/32 patients (3 to 6 samples/patient) and extensive sampling in 10/32 patients (18 to 20 samples/patient). In additional 12 patients pericardial biopsy was performed without pericardioscopy, under fluoroscopic control. Endoscopic visualization was clearly superior when pericardial effusion was partially replaced with 100 to 300 ml of air (29/32 procedures) in comparison to 3/32 procedures in which the pericardial effusion was replaced with warm normal saline (37 degrees C). In patients with hemorrhagic effusion (12/32), we either repeatedly injected and removed 100 to 150 ml volumes of normal saline (37 degrees C), or postponed pericardioscopy for 2 to 3 days of active drainage. The specificity of endoscopic findings is low and not decisive for the diagnosis. However, pericardioscopy is significantly contributing to the diagnostic value of pericardial biopsy, especially regarding establishing the new diagnosis and etiology of the pericardial disease. Sampling efficiency was also significantly higher for procedures using aimed pericardial biopsy with standard and extensive sampling compared to procedures performed under fluoroscopy: 86.2%, 87.3%, and 43.7%, respectively. No major complications directly related to the procedure were encountered. Minor complications included: short-run ventricular tachycardia (6.3%), pain at the sheath entry site (75%) and transient fever (37.5%). In conclusion, pericardioscopy with Olympus HYF-1T, after air instillation, is a technically complex, but safe procedure that enables excellent visualization and extensive pericardial sampling with improved diagnostic value of pericardial biopsies.

New directions in diagnosis and treatment of pericardial disease. A project of the Taskforce on Pericardial Disease of the World Heart Federation.

New directions in the diagnosis and treatment of pericardial diseases synthesize the achievements of modern imaging with molecular biology and immunology techniques. Comprehensive and systematic implementation of new techniques of pericardiocentesis, pericardial fluid analysis, pericardioscopy, epicardial and pericardial biopsy, as well the application of comprehensive molecular biology and immunology techniques for pericardial fluid and biopsy analyses have opened new windows to the pericardial diseases, permitting early specific diagnosis and creating foundations for etiologic treatment in many cases. In patients with recurrent pericarditis, resistant to conventional treatments, as well as in patients with neoplastic pericarditis an alternative intrapericardial treatment regimen was suggested by the Taskforce on Pericardial Diseases of the World Heart Federation. Intrapericardial application of medication avoids systemic side effects with increased local efficacy. The following protocols are proposed: CIRP (colchicine in recurrent pericarditis)--colchicine vs placebo in chronic/recurring pericarditis without pericardiocentesis; TRIPE (triamcinolone in pericardial effusion)--intrapericardial instillation of triamcinolone + 6 months colchicine vs pericardial puncture without instillation + 6 months colchicine; NEPIN (neoplastic effusion and pericardial instillation)--pericardiocentesis and drainage + intrapericardial instillation of cisplatin or thiotepa.

Intrapericardial treatment of autoreactive myocarditis with triamcinolon. Successful administration in patients with minimal pericardial effusion.

A major clinical drawback in the treatment of autoreactive pericarditis is its inherent feature to relapse. Intrapericardial treatment with triamcinolone was reported to be efficient in patients with large, symptomatic autoreactive pericardial effusions, avoiding side effects of systemic treatment as well as compliance problems. Intrapericardial treatment with 300 mg/m2 triamcinolone was for the first time performed in patients with autoreactive myopericarditis and minimal pericardial effusions (75 to 110 ml). After 12 months of follow-up both patients are asymptomatic and there were no further recurrences of pericardial effusion. Pericardiocentesis in these patients was performed with the application of the PerDUCER device, guided by pericardioscopy. This device has a hemispherical cavity at the top of the instrument connected with a vacuum-producing syringe. In this cavity the pericardium is captured by vacuum and tangentially punctured by the introducer needle. Pericardium that can be captured, must be up to 2 mm thin to fit into the hemispherical cavity. Pericardioscopy performed from the anterior mediastinum significantly contributed to the success of the procedures enabling visualization of the portions of the pericardium free of adipose tissue or adhesions, suitable for puncture with the PerDUCER. In conclusion, intrapericardial treatment of symptomatic autoreactive myopericarditis with minimal pericardial effusion was safely and efficiently performed in 2 patients. Pericardiocentesis was enabled by means of the PerDUCER device, facilitated by pericardioscopy.

Myotonic dystrophy and cardiac disorders.

Myotonic dystrophy (MD) is a multisystem disease affecting numerous organs and systems. Cardiac involvement is frequent. Sudden death, due to fatal cardiac rhythm and conduction disturbances occurs in 30% of patients with MD. The aim of this study was to assess the possibilities and methods of early detection of myocardial and conduction system disturbances. ECG, 24-hr Holter monitoring, echocardiography and electrophysiologic studies of the conduction system (electrophysiologic study) were carried out in 45 patients. Analysis of late ventricular potentials was done in 36 patients. Genetic studies revealed multiplication of CTG triplets in all patients. Cardiological abnormalities were detected in 89% of our patients. Disturbances of intraventricular conduction with prolongation of HV interval were most frequent (72%). Electrophysiologic study was the most sensitive method for detecting heart involvement in MD (positive findings in 87% patients). Abnormal findings were also discovered by Holter monitoring (64%), ECG (58%), analysis of late ventricular potentials (55%) and by echocardiography in 46% patients. The results of this study indicate a high rate of cardiac involvement in MD.

Pathohistological changes in endomyocardial biopsy specimens in patients with myotonic dystrophy.

BACKGROUND: Endomyocardial biopsies in patients with myotonic dystrophy (MD) have, so far, shown changes such as myofibrillar degeneration, mitochondrial abnormalities, focal myocarditis, fibrosis and fatty infiltration of the myocardium and the conduction system. METHODS: This study presents the results of endomyocardial biopsy in 10 patients with MD. Endomyocardial biopsy was carried out using King's bioptome. RESULTS: In two patients with servere MD biopsy specimens showed changes compatible with border line myocarditis. In five patients with moderate to severe forms of MD fibrosis and fatty infiltration of the myocardium were found in addition to degenerative changes and hypertrophy of muscle fibers. Three patients with mild MD had non-specific degenerative and hypertrophic myocardial changes. The histological changes described above were present in patients without cardiological symptoms and in those with normal ECG and echocardiographic findings. Only two of the 10 patients in whom endomyocardial biopsy was done complained of fatigue and occasional palpitations while the rest were asymptomatic. One patient with focal myocarditis had ECG signs of left bundle branch block and echocardiographic evidence of reduced left ventricular contractility. Five patients with signs of endomyocardial fibrosis only had an abnormal Q wave on ECG recordings. The remaining five patients with border line myocarditis i.e. with degenerative and hypertrophic myocardial changes had normal ECG and echocardiographic findings. CONCLUSIONS: These results stress the significance of endomyocardial biopsy in detecting myocardial pathologic changes in patients with MD.

Initial clinical experience with PerDUCER device: promising new tool in the diagnosis and treatment of pericardial disease.

BACKGROUND: The idea to enter the normal pericardial sac safely was unrealistic until recently. The development of a novel instrument (PerDUCER pericardial access device) for percutaneous access to the pericardium could potentially have a significant impact, not only on patients with pericardial diseases but even more, or primarily, on diagnosis and treatment of myocardial and coronary disease and arrhythmias. HYPOTHESIS: The overall objective of the present study was to evaluate the feasibility and safety of the percutaneous pericardial access with PerDUCER in patients with pericardial disease, and to analyze our initial experience with this new technique, with particular emphasis on sequential procedural steps. METHODS: The device was studied in five patients with pericardial disease (two men, mean age 50.4 years, range 30-68, four with normal body mass index). The procedure consists of two distinct techniques: (1) access to the mediastinal space, and (2) pericardial capture, puncture, and insertion of the guidewire. Access to the mediastinal space includes the introduction of a blunt cannula, a 0.038 guidewire, a dilator-introducer sheath set, and insertion of the PerDUCER device. Key points of the PerDUCER procedure are as follows: introduction of the blunt cannula without resistance, placement of the dilator-introducer sheath at the upper third of the heart, systolic movements of the PerDUCER device, successful vacuum and capture of pericardium, puncture and introduction of the intrapericardial guidewire. RESULTS: Access to the mediastinal space was accomplished in four of five patients, as were pericardial capture and probably puncture. However, despite numerous successful captures and probably punctures of pericardium, we were not able to confirm introduction of the intrapericardial guidewire into the pericardial cavity in any of our patients (0/5). The procedure was very well tolerated in all patients (5/5). No major complications developed during the procedure, bearing in mind that the intrapericardial placement of the guidewire was not achieved. Minor complications included pain at the dilator-introducer sheath entry site (5/5) and mild transient fever (2/5). CONCLUSIONS: According to the present experience, we believe that, with minor modifications, the PerDUCER device could be successfully implemented for pericardial entry in patients with pericardial disease. Further studies are needed to evaluate the feasibility and safety of this new instrument in patients with a normal pericardium. This could open a most exciting spectrum of possible implementations of the device in the future.

Computed tomography image analyzer: segmentation applying active contour models--"snakes".

Many diagnostic and therapeutic procedures depend on medical images. In order to overcome imperfections of obtained images which are due to acquisition process and to obtain new information from available images, many techniques have been developed. In this study relatively new method of image segmentation, active contour model--"snakes" was applied in analyzing computed tomography (CT) images in patients with acute head trauma. Using this method, lesion to brain (LBR) and ventricle to brain ratio (VBR) were obtained accurately. Quantitative variable LBR, is significantly higher in patients with other pathologic CT findings and who do not survive during hospitalization. Thus, by applying segmentation "snakes" model it is possible to extract maximum information from available CT scans. These variables could be basis for medical decision making in patients with acute head trauma.

Myocardial catecholamines in primary heart muscle disease: fact or fancy?

The pathophysiological role of myocardial catecholamines in cardiomyopathies is still not completely understood. We there-fore assessed myocardial catecholamine concentrations (MCC) in 34 patients with hypertrophic cardiomyopathy (HCM) (76.5% males; mean age 46.7 +/- 11.6 years; left ventricular ejection fraction [LVEF] 75.3 +/- 9.8%) and in 32 patients with dilated cardiomyopathy (DCM) (87.5% males, mean age 43.1 +/- 12.5 years, LVEF 34.9 +/- 8.3%). Initial assessment included clinical work up, cardiac catheterization and endomyocardial biopsy. Myocardial norepinephrine (MNEC), epinephrine (MEC), and dopamine (MDC) concentrations in endomyocardial biopsy samples were measured using the catechol-O- methyl transferase radioenzymatic method. Significantly higher MNEC and MEC were demonstrated in HCM than in DCM patients (MNEC: 781.9 +/- 125.8 ng.g-1 fresh myocardial tissue (ft) HCM vs 262.6 +/- 68.9 ng.g-1 ft DCM, p < 0.01; and MEC: 91.6 +/- 13.9 ng.g-1 ft HCM vs 35.8 +/- 6.2 ng.g-1 ft DCM, P < 0.01). The difference in MDC did not reach statistical significance (76.1 +/- 8.3 ng.g-1 ft HCM vs 70.1 +/- 11.8 ng.g ft DCM; P > 0.05). In addition, we compared the MCC levels in 24 patients, clinically presented as dilated cardiomyopathy categorized according to the various aetiologies: 12/24 with primary DCM (75.0% males, mean age 49.6 +/- 9.5 years; LVEF 25.8 +/- 63%), 7/24 with alcohol-induced heart disease (85.7% males, mean age 46.8 +/- 7.1 years; LVEF 26.4 +/- 4.6%), and 5/24 with hypertensive heart disease (100% males, 45.1 +/- 10.6 years; LVEF 25.6 +/- 9.1%), but no significant difference was found among them (P > 0.05). There was no significant difference in tissue dopamine concentrations.

[Method of information synthesis--meta analysis of endomyocardial biopsy complications]. / Metod sinteze podataka--meta-analiza komplikacija biopsije endomiokarda.

The "information explosion" in the last 20 years has created a need for technique that synthesizes information from various sources. One of the methods for synthetasing information from various independent but similar studies is meta analysis. The aim of this study was to estimate complication rate of endomyocardial biopsy and therefore to assess its routine clinical applicability. In order to identify published studies regarding endomyocardial biopsy between 1980-1993, we performed computer and manual literature search. A total of 255 papers were retrieved but only 18 studies fulfilled separately predefined inclusion/exclusion criteria for meta analysis of complications. For each study, numerical weights were calculated according to the sample size and magnitude of effect size (proportion of each of the observed diagnostic categories). Weighted average of proportions was used to obtain a 95 posto study-specific confidence interval (CI) for each category. To compare incidence of complications of endomyocardial biopsy of the right to the endomyocardial biopsy of the left ventricle, modified Mantel-Haenszel test of the effect size for summarizing data from individual studies was used. Complication rate in analyzed studies was compared to the Poisson's rule of rare events and showed no significant difference (Chi2=2.02, p>0.05). Mild complications were present in 1.55 posto pts (95% CI 1.27-1.87%) while severe complications were present in 0.62% (95% CI 0.47-0.88%). Heart perforations, included in severe complications, were present in 0.31% pts (95% CI 0.16-0.46%). Overall complication rate was 1.68% (95% CI 1.41-1.96%). According to the results obtained, the overall complication rate was demonstrated to be significantly higher following the right (prv=6.5%) than following the left (plv=3.7%) ventricular endomyocardial biopsy (Chi2 =8.784, p<0.05). Thus, using meta analysis complication rate was estimated objectively. These pooled data suggest that endomyocardial biopsy is a safe procedure with infrequent complications. They were estimated to occurred more often during endomyocardial biopsy of right ventricle.

Endomyocardial biopsy: a meta-analysis of diagnostic value.

To clarify the controversy of endomyocardial biopsy (EMB) in terms of its diagnostic value, we performed a meta-analysis of EMB studies published between 1982 and 1993, including our own experience. A total of 255 articles was retrieved using both a computer search of the Medline database and a manual bibliographic search, but only 30 studies with 4,313 patients met the predefined inclusion/exclusion criteria. The diagnostic value of EMB was classified into four categories, according to the effect of EMB findings on the discharge diagnosis: aetiology uncovered, new diagnosis of heart muscle disease (HMD) revealed, clinical diagnosis confirmed, and no useful information obtained. Clarification of aetiology of HMD was reported in 28 out of 30 studies with a total of 4,195 patients and it was achieved by EMB in 17.9% of these patients (95% confidence interval (CI) was 16.8-19.1%). A new unexpected diagnosis of HMD was arrived at in 25 of 30 studies (3,947 patients) and this occurred in 19.3% of patients (95% CI = 18.1-20.6%). Confirmed clinical diagnosis of HMD by EMB was covered by 12 studies (1,231 patients) and was proven in 40.1% of patients (95% CI = 37.3-42.7%). EMB not providing any useful clinical information was mentioned in seven of 30 studies (857 patients); this happened in 5.9% of patients (95% CI = 4.5-7.4%). Therefore, these results confirmed the remarkable diagnostic value of EMB. It was equally helpful in all diagnostic categories and had considerable overall diagnostic utility.

The incidence of myocarditis in endomyocardial biopsy samples from patients with congestive heart failure.

We present the combined experience of three Yugoslavian cardiovascular centers in the application of endomyocardial biopsy for the diagnosis of myocarditis in patients who present clinically with congestive heart failure. The study group comprised 107 patients (mean age, 40.8 years; range, 19 to 61 years). On the basis of patient history and diagnostic tests, the following clinical diagnoses were established: dilated cardiomyopathy (85), myocarditis (16), and alcohol-induced heart disease (6). EMB samples were taken from the left ventricle (95) or both ventricles (12) by use of a King's College bioptome, with a mean of 3.2 samples per patient. Histologic evidence of myocarditis was noted in 10 of 85 patients (12%) with a clinical diagnosis of dilated cardiomyopathy, in 2 of 6 patients (33%) with alcohol-induced heart disease, and in 12 of 16 patients (75%) with a clinical diagnosis of myocarditis. There was confirmation of the clinically suspected diagnosis in 63% of cases, a change of diagnosis based on histology in 15% of cases, and nonspecific findings in 22%. However, useful information was obtained in 78% of the cases, and there was a 22% incidence of histologically proven myocarditis for the entire group. Our results indicate that endomyocardial biopsy is beneficial in determining the true incidence of myocarditis in patients with a clinical presentation of dilated cardiomyopathy.