Rheumatic Myocarditis: A Poorly Recognized Etiology of Left Ventricular Dysfunction in Valvular Heart Disease Patients

Background: Heart failure occurs in ~10% of patients with acute rheumatic fever (RF), and several studies have shown that cardiac decompensation in RF results primarily from valvular disease and is not due to primary myocarditis. However, the literature on this topic is scarce, and a recent case series has shown that recurrent RF can cause ventricular dysfunction even in the absence of valvular heart disease.Methods: The present study evaluated the clinical, laboratory and imaging characteristics of 25 consecutive patients with a clinical diagnosis of myocarditis confirmed by 18F-FDG PET/CT or gallium-67 cardiac scintigraphy and RF reactivation according to the revised Jones Criteria. Patients underwent three sequential echocardiograms at (1) baseline, (2) during myocarditis and (3) post corticosteroid treatment. Patients were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episodes.Results: The median age was 42 (17–51) years, 64% of patients were older than 40 years, and 64% were women. Between Group 1 (n = 16) and in Group 2 (n = 9), there were no demographic, echocardiographic or laboratory differences except for NYHA III/IV heart failure (Group 1: 100.0% vs. Group 2: 50.0%; p = 0.012) and LVEF (30 [25–37] vs. 56 [49–62]%, respectively; p < 0.001), as expected. Group 1 patients showed a significant reduction in LVEF during carditis with further improvement after treatment. There was no correlation between LVEF and valvular dysfunction during myocarditis. Among all patients, 19 (76%) underwent 18F-FDG PET/CT, with a positive scan in 68.4%, and 21 (84%) underwent gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, there was no difference between these groups.Conclusion: Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite valvular disease, and it is reversible after corticosteroid treatment

Prognostic implications of the diagnosis of myocardial fibrosis using cardiovascular magnetic resonance in patients with severe aortic valvular heart disease submitted to surgery

INTRODUÇÃO E OBJETIVO: Pacientes com estenose aórtica e insuficiência aórtica apresentam mecanismos miocárdicos de hipertrofia que incluem estímulos celulares que favorecem a formação de fibrose. É bem estabelecida a importância da ressonância magnética cardiovascular na avaliação da estrutura e função miocárdicas, além do diagnóstico de fibrose focal, através do realce tardio. Através de uma nova metodologia de avaliação de fibrose miocárdica difusa pela ressonância, chamada Mapa T1, pode-se quantificar o volume extracelular miocárdico. O objetivo deste estudo é avaliar o impacto prognóstico pós-operatório da fibrose miocárdica difusa pré-operatória expressa pela fração do volume extracelular (ECV) e pelo volume extracelular indexado (iECV) em pacientes com valvopatia aórtica importante submetidos a cirurgia. MÉTODOS: Foram incluídos pacientes com estenose ou insuficiência aórtica importante com indicação de cirurgia. Foram excluídos pacientes com coronariopatia obstrutiva (lesões > 50%) ou com diabetes em uso de insulina. Foram realizadas ressonâncias magnéticas cardiovasculares até 3 meses antes e entre 6 e 9 meses após a cirurgia valvar. O desfecho clínico composto primário consistiu em óbito, acidente vascular cerebral, reoperação ou dispneia classe funcional III ou IV no período de acompanhamento. O desfecho clínico composto secundário consistiu em dispneia classe funcional III ou IV ou eventos do escore da Sociedade de Cirurgiões Torácicos americana (STS) em 30 dias. RESULTADOS: Um total de 99 pacientes foi incluído nas análises (32 com insuficiência aórtica e 67 com estenose aórtica). O ECV e o iECV não foram preditores dos desfechos clínicos compostos primário ou secundário (p>0,05). As variáveis preditoras independentes do desfecho clínico composto primário foram uso de diurético na avaliação inicial (Hazard ratio: 3,653 [1,25110,655], p=0,018) e tempo de circulação extracorpórea (Hazard ratio: 1,019 [1,0041,035], p=0,013). A presença de realce tardio foi preditora independente do desfecho clínico composto secundário (Razão de chances: 4,937 [1,402 Resumo 17,390), p=0,013). Os pacientes com insuficiência aórtica apresentaram maiores valores de ECV (todos os valores de p0,10 para ambas as valvopatias). Com relação ao ECV, o mesmo se mantém estável (todos os valores de p>0,60) nos pacientes com insuficiência aórtica, e apresenta elevação naqueles com estenose aórtica (todos os valores de p50% obstructive coronary disease or insulin-dependent diabetes mellitus. Cardiovascular magnetic resonances were performed 3 months prior and 6 through 9 months after surgery. The primary composite clinical endpoint consisted in death, stroke, reoperation, or dyspnea (class III or IV) during the follow-up period. The secondary composite clinical endpoint consisted in dyspnea (class III or IV) or one of the clinical events of the score of the Society of Thoracic Surgeons (STS) within 30 days of surgery. RESULTS: 99 patients were included in the analyses (32 with aortic regurgitation and 67 with aortic stenosis). ECV and iECV were not predictors of the primary or secondary clinical composite endpoints (p values >0.05). The independent predictors of the primary clinical composite endpoint were the use of diuretics in the first visit (Hazard ratio: 3.653 [1.25110.655], p=0.018) and the time of extracorporeal circulation (Hazard ratio: 1.019 [1.0041.035], p=0.013). The presence of late gadolinium enhancement areas was an independent predictor of the secondary clinical composite endpoint (Odds ratio: 4.937 Abstract [1.40217.390), p=0.013). The patients with aortic regurgitation had higher values of ECV (all p values 0.10 in both aortic diseases). Regarding ECV, it was stable (p values >0.60) in the patients with aortic regurgitation and increased in the patients with aortic stenosis (p values <0.05). CONCLUSIONS: The parameters of diffuse myocardial fibrosis (ECV and iECV) were not predictors of the clinical events nor of the primary neither of the secondary clinical composite endpoint. Late gadolinium enhancement areas were not predictors of the primary clinical composite endpoint and were independent predictors of the secondary clinical composite endpoint. The patients with aortic regurgitation or aortic stenosis developed different patterns of myocardial fibrosis reversal after surger