Characteristics of patients with advanced heart failure having eosinophilic infiltration of the myocardium in the recent era.

Eosinophilic infiltration of the myocardium is occasionally observed as an incidental histological finding in endomyocardial biopsy specimens before heart transplantation (HTx) as well as in explanted heart obtained at the time of HTx. However, the indications for HTx in these patients have not yet been fully established. We investigated the pre-HTx characteristics of the recipients with myocardial eosinophilic infiltration in the explanted heart and diagnosed as hypersensitivity myocarditis (HSM) (21 among 761 recipients, 2.8%). Dobutamine, a common cause of HSM, was administered to 12 patients (57%). Ten patients (47.6%) were on milrinone and 4 (19.0%) were on ventricular assist devices. Post-transplant survival of HSM patients was comparable to that of patients transplanted for active myocarditis or other cause of heart failure. In conclusion, myocardial eosinophilic infiltration is associated with multiple medications in patients with advanced heart failure; however, it does not affect the post-transplant prognosis.

Hypersensitivity myocarditis and outcome after heart transplantation.

BACKGROUND: Hypersensitivity myocarditis (HSM) is associated with the use of multiple drugs and has been occasionally observed in patients awaiting heart transplantation (HTx). However, whether HSM at the time of HTx affects long-term prognosis, including acute cellular rejection (ACR) and antibody-mediated rejection (AMR), after HTx remains unclear. METHODS: Between 2000 and 2010, 759 consecutive patients underwent de novo HTx at Columbia University Medical Center and were retrospectively reviewed. Clinical characteristics and pathologic findings of patients with a pre-HTx HSM diagnosed by histologic evaluation of the explanted heart were analyzed. Prognosis after HTx was compared between patients with and without pre-HTx HSM. RESULTS: HSM was observed in 21 patients (2.7%), but in no case was HSM clinically diagnosed. Twelve patients (57%) had received dobutamine infusions. HSM patients had varying degrees of perivascular or interstitial eosinophilic infiltrates with rare necrosis in the explanted heart. The number of biopsy specimens diagnosed with ACR (International Society for Heart and Lung Transplantation Grade ≥2R) was 11 (3.9%) in HSM patients and 197 (2.2%) in patients without HSM (p = 0.06) during the first year post-HTx, and 11 (3.8%) in HSM patients and 78 (1.5%) in patients without HSM (p = 0.006) after the second year post-HTx. Post-HTx survival did not differ in patients with or without pre-HTx HSM. CONCLUSIONS: HSM at the time of HTx is associated with an increased frequency of late ACR after HTx. Post-HTx survival is not influenced by pre-HTx HSM.

A case of cardiac sarcoidosis masquerading as arrhythmogenic right ventricular cardiomyopathy awaiting heart transplant.

We report a case of 45-year-old man, who was diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) and presented with right ventricular (RV) enlargement with a global decrease in RV contractility accompanied by impairment of left ventricular function. He was placed on the heart transplant waiting list. Endomyocardial biopsy from RV septal wall did not show any evidence of sarcoidosis or inflammatory change. Four years after he was put on the heart transplant waiting list, a computed tomography chest scan for the purpose of anatomical evaluation for coronary sinus prior to biventricular pacing lead implantation incidentally showed bilateral hilar lymphadenopathy, which suggested the possibility of sarcoidosis. Biopsy of the inguinal lymph node pathologically was consistent with sarcoidosis. The 2[18F]fluoro-2-deoxy-d-glucose positron emission tomography scanning (FDG-PET) demonstrated intense uptake in the myocardium, and the patient was finally diagnosed as having cardiac sarcoidosis. After steroid treatment, the abnormal FDG-PET uptake disappeared. The patient therefore represented a case of cardiac sarcoidosis masquerading as ARVC. It should be recognized that RV involvement is one of the manifestations in cardiac sarcoidosis.