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Slide Seminar
Endomyocardial biopsy

September 2nd, 17.00-19.00 Room 5C
Chairpersons: Allard van der Wal (Netherlands) and Rosa Henriques de Gouveia (Portugal)
Case 1
Presented by: Ivana Kholová, Tampere, Finland

A 56-year-old female presented with collapses. At hospital, total block was diagnosed on ECG. She had no previous diseases, nor medications. Laboratory tests were normal. Heart ultrasound was normal. No family history of heart diseases. Cardiac biopsy was performed.
Slide 1 (AB-PAS)Slide 2 (Masson Trichrome)
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Case 2
Presented by: Patrick Bruneval, Paris, France

A 46 year-old Caucasian woman had a diagnosis of systemic lupus erythematosus in 1987, presenting arthritis, dermatological symptoms, and glomerulonephritis (class V, WHO classification) that led to end stage renal failure.

At the age of 72 years, while she was on dialysis for 3 years, she was admitted in renal transplant care unit for renal transplantation. Cardiac screening before transplantation demonstrated a left anterior fascicular block with right bundle branch block, an anteroseptal ST elevation at ECG. The coronarography did not demonstrate any abnormality. Transesophageal echography showed a preserved left ventricular systolic function (LVEF 55%) with a moderate diastolic dysfunction, a concentric left ventricular hypertrophy (16 mm) and slightly elevated right-sided filling pressures. A cardiovascular magnetic resonance evidenced a diffuse subepicardial late gadolinium enhancement consistent with a myocarditis or an infiltrative cardiomyopathy. The patient had no biological inflammatory syndrome, no outburst of her disease and anti-nuclear factors remained inconspicuous. Three months later (September 2011) the patient had a double renal transplant. Renal function was consecutively improved but a chronic renal dysfunction subsided with a serum creatinin at 149 µmol/l. The patient then progressively developed a dyspnea related to a class-III NYHA cardiac failure.

As the heart failure worsened, she was referred in September 2012 for endomyocardial biopsy. The ECG showed a first degree atrioventricular block. Two weeks later she died from cardiogenic shock. An autopsy was performed and confirmed cardiomegaly at 590 g, with mild dilatation and symmetric hypertrophy of the left ventricle (2cm). The epicardial coronary arteries were free of significant lesions.
HEPASSirius red
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Case 3
Presented by: Rosa Henriques de Gouveia, Coimbra & Lisbon, Portugal

“C4d immunostaining in EMB case”

A 49 year-old male with a congenital cardiopathy – Ebstein’s Disease –, diagnosed during infancy, was asymptomatic until his thirties. In 1998, he first complained of fatigue and palpitations. In 2003 and despite medical therapy, he was submitted to implantation of goretex ring at the tricuspid valve and to surgical cryoablation due to class III-IV NYHA cardiac insufficiency and atrial fibrillation. Afterwards, a pacemaker was implanted. In February 2012, he was submitted to heart transplant, without complications, leaving the hospital in March 2012. Myocardial biopsies have been performed to monitor rejection status. The images / slides presented are from a November 2012 biopsy.
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Case 4
Presented by: Aryan Vink, Utrecht, Netherlands

Myocardial biopsy of a patient with dilated cardiomyopathy and congenital cataract

The patient is 39 year old woman that presented with complaints of fatigue and nausea during exercise. She was diagnosed with dilated cardiomyopathy and a preventive Implantable Cardioverter Defibrillator was implanted.

She had a history of congenital posterior polar cataract. Family history: her father, brother and uncle died at young age due to dilated cardiomyopathy (father at 29 years, brother at 23 years). She has 3 children: both her sons also have congenital cataract, but no signs of cardiomyopathy. Her daughter has no diseases.

Four years later, at age 43, she presented with forward failure and panischemia on the electrocardiogram due to right and left ventricular failure. A biventricular extracorporeal circulatory assist device (Centrimag) was implanted. Two months later the right ventricular function was normalized. After weaning of the right ventricular assist device, the extracorporeal left ventricular assist device (LVAD) was replaced by an internal LVAD (HeartMate II). The cardiac muscle that was removed at the apex during this procedure was submitted for histopathological examination.
Slide 1Slide 2 (HE)
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Case 5
Presented by: Professor Mary Sheppard, London, United Kingdom

A previously healthy 54-year-old man presented with dyspnoea and syncope. The admission ECG showed anterolateral T-wave inversion, and the troponin-I concentration was raised (0·20 μg/L). He was treated for an acute coronary syndrome. Echocardiography showed concentric left ventricular hypertrophy with inferoposterior hypokinesis, and mild systolic dysfunction.

The right ventricle (RV) was slightly dilated with mild systolic dysfunction. Coronary angiography showed mild atheroma; he was managed medically. He presented again to his local hospital the day after discharge, with further syncope and dyspnoea. Repeat echocardiography showed progressive cardiac dysfunction with moderate RV dilatation and severe RV systolic dysfunction. He was transferred to our centre.Cardiac MRI showed several diffuse cardiac masses involving all four cardiac chambers and encasing the coronary arteries and ascending aorta;
MRIEndomyocardial biopsyEndomyocardial biopsyCellular infiltrateCellular infiltrateCD45CD20
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