Panel dyskusyjny 6

Dziękujemy wszystkim prelegentom.Uh, I would like tothank all the, um, speakers inthis session, and, um, uh,we have a great honor to,to welcome today our specialguest, Anna Barituso- Baritussio from, uh,Padova, Italy.Uh, Anna is, uh, I,I would say for sure, uh,world, world rec-recognized leader, um,or specialist in cardiac magnetic resonance.So it is really agreat pleasure to have you here.

Um, and maybe I willask the first, uh, question toyou.Uh, what do you think,what is your opinion about, uh,this common name, thatis used in this, um, recent,uh, guidelines on myocardial andpericardial diseases, uh, uh, which isInflammatory Myopericardial Syndrome?Is it g- is ita good direction?

Uh Thank you very much.First of all, thank youvery much for having me, um,again.I'm always very happy.Uh, I, I took toolong to talk in my presentation,I think, so apologies forthat.Um, your question is very,um, interesting.Um, uh, if I haveto say, I'm not a hugefan, um, b-because I thinkit might be confusing.Uh, if you're not reallyaware of the two, uh, entities,uh, you might think theyare the same and could betreated the same, diagnosed thesame way.I'm not really sure thisapplies to all the cases.Um, I do acknowledge, youknow, sometimes you have a patientwith myocarditis that may havesome pericardial effusion, so in thatsense, the pericardium might beinvolved.You might sometime have patientswith pericarditis that have some minorincrease, um, in their troponinlevels.But, um, um, a-as longas we understand that there aredifferent features, um, it's safeif it simplifies the way wecan, um, you know, uh,explain things to people.But I do think stillthat they're very different and shouldbe treated, um, as such.I don't know what youand your colleagues think about this,but this is my, mythought.

Uh, I think, I thinkwe share, um, the same ideaas you.And, um, uh, and mysecond thought is you come from,uh, a center which, um,where there is a huge trustand confidence in endomyocardial biopsy.And, uh, particularly these guidelines,uh, said that, um, cardiac magnetic,magnetic resonance is now onthe top of this diagnostic processladder, uh, along with, um,endomyocardial biopsy.Uh, and for me personally,and, um, but, but I'm maybebiased, uh, because, um, uh,we share, um, your vision on,uh, diagnostic process in, uh,endom- of myocarditis.But, um, particularly in patientswith chronic, uh, heart failure, suspectedmyocarditis, uh, can we reallytrust on cardiac magnetic resonance?Uh, and is it ableto give a definite diagnosis?

No, I, I agree withyou.Well, you know, I'm biasedas well because I work withAlida Caffaro, and she's as-strong believer of the importance ofhaving histology as a confirmation.Uh, the point is that,um, as I've shown in onecase, you may have patientsthat have active myocarditis on histology,but they have been, youknow, presenting maybe a bit latewith heart failure or aWhitney presentation.

And in those cases, you'veseen studies show that, um, lessthan half of these patientshave a positive CMR.So if we just relyon CMR, we may miss, uh,not only the, the diagnosis,but we may miss chances toproperly, uh, cure the patients.

So, you know, um, I'ma bit concerned of putting boththings at the same level,unless we do know that thereare some limitations on bothsides, uh, because EMB is notperfect either.You may still miss adiagnosis on EMB as well.But I do think thatwhenever your clinical suspicion is veryhigh for myocarditis, even ifyou have a negative CMR, evenif you have a negativebiopsy, if your clinical suspicion isstill very high, you shouldprobably pursue it.

Um, but, you know, ifyou're reading the guidelines, uh, youknow, although they put thesame, um, you know, they puton the same level CMRand endomyocardial biopsy, then if youread it from the tables,they clearly state that CMR providesa clinical diagnosis, not reallyhistology.So I think we probablydo believe the same things, butwe have different way ofsaying these things.Don't know your opinion aboutthat.

Uh, uh, I would saythat we observe the same asyou said in our clinicalpractice, that only maybe thirty tofifty percent of patients with,uh, chronic, um, persistent myocar- myocarditiswill have a positive resulton a cardiac magnetic resonance, andonly biopsy can, um, can,um, give us a true answer.

Uh, and on the otherhand, uh, what is important problemhere, and it is, uh,as well, uh, we can seeit in, in these guidelines,um, when you have to decidewhat kind of treatment, uh,prescribed to your patient, uh, the...It, um, it depends onthe histology.So we cannot, we cannotdo this based on, um, cardiacmagnetic resonance only. Yeah, you're absolutelyright.And I don't think CMRwill ever be able to distinguish,you know, viral from, uh,autoimmune.So if we have todecide on a specific treatment, histologyis the way.So I don't think thiswill ever change, to be honest.

And, and last question, uh,because we, we try to use,um, a PET scan, uh,with, uh, fluorodeoxyglucose in, in some,uh, cases like, like you--like we said here, uh, likewe discussed.So how often, uh, doyou really use, uh, PET inthose patients?

So honestly, um, we onlydo PET when we have thesuspicion of sarcoid.

We never do PET forpatients with myocarditis.I wouldn't...You know, the other typeslike lymphocytic, eosinophilic.Uh, I, I think thereare also not so many studiesthat have specifically used PET,uh, in these patients.So honestly, in our dailypractice, we only, uh, perform itin patients with suspected orknown sarcoid when we want tosee, uh, not only theinvolvement of the heart, but most,uh, frequently to see ifwe have other areas outside theheart that could be moreeasy to biopsy and have, um,histological diagnosis.So now maybe Agata.

Um, yeah.Hi, Ana.[laughs] I would like tomeet you.And thank you very muchfor your, uh, um, uh, yourbeautiful speech today.Uh, we are happy forhaving you.

Um, but I have alsoone question to you.Um, conceptional problem, uh, withthe current guidelines and CMR approach.I think we, uh, gain,um, sensitivity with, uh, T2-- uh,T2, um, T2 mapping.But I think we, um,uh, is, is the cost of,uh, specificity, and we are,uh, now, uh, probably will havea problem with over-diagnosing, um,di-diagnosis of myocarditis.And it will, um, provide,um, like, it, it will leadto, um, whole stack of,uh, myocarditis patients with different, um,different, um, histology, uh, confirmationand CMR confirmation.Uh, um, yeah.

So what do you thinkabout it?Because now w-with, um...It a-also may be aproblem, uh, when we have apro- patients with, uh, um,symptoms that we, um, we are,like, obligatory to perform CMR.Uh, and it, uh, willlead us to, um, uh, like,um, some imaging definition, diagnosis,not, uh, clinician diagnosis.Uh, and maybe we willhave this problem with over-diagnosis onthe patient, uh, especially whenwe also provide a new, um,common definition of inflammatory myopericardialsyndrome.So it will be awhole stack of, uh, these, um,entities.

Yes, I agree with you,and I'm happy to see we'renot the only one withthis issue.Uh, we've had as wella sort of, um, pandemics ofmyocarditis, uh, after the introductionof mapping.Um, I think it's veryimportant that, um, if we arethe one to, uh, producethe report, uh, or if weare the, the one whoreceive the report from CMR, weneed to have the referencevalues for T1 and T2 mapping

in that specific scanner, becauseit changes from scanner to scanner.Uh, and it's very importantto know how, um, you know,distant from the normal rangethe, the values are.

Because, you know, if normalis fifty and you have fifty-one,I wouldn't call it amyocarditis just based on one millisecond,you know.It's just numbers.If you, if your ROIis a bit within the heart,the, the blood pool, youget completely, uh, messed up numbers.

So it's very, very important,specifically with mapping, that we stickto the clinical context.Which is, I understand, difficultfor those who just see theCMR scan, right?Because the patient is notjust the images as in, youknow, the...When you do the echo,the patient is not just theecho.

So it's very important thatwhoever gets the report puts thenumber in the context.But to do so, it'svery important to have the referencevalues.And this is not, um,this does not happen everywhere.In Italy, for example, notall the centers provide their normalvalues, the reference values, andthis is very important to have.Because otherwise you end up,uh, calling myocarditis pretty much everyone.So it happened to usrecently, uh, eighty, eight zero, uh,year old, uh, man witha severe aortic stenosis that by,I don't know what reason,had slightly increase in T2 andT1, and that was calledmyocarditis, which by age is veryunlikely, you know.And you end up havingover-diagnosis, which is not good.

I think, you know, w-wemay use at our advantage T1and T2.So if you see someedema or late enhancement on standardsequences, but maybe it's veryfaint and you're not very convinced,if you have slightly increasedT1 and T2 values in thoseareas, you may be, youknow, supported in calling it abnormal.But otherwise, I would bevery, very cautious.

Yeah, I agree with you.Thank you.Thank you.And we als-also have, uh,one question in our chat toyou.Do you face any problemsin T, T1 and T2, uh,mapping in patient with, uh,um, uh- Cardiac implanted devicesYes, that's

a very, very good question.Very good question.So, you know, um, likewise,if you have like, for example,a bundle branch blocks, youmay have the same issue becauseyou basically just trace anROI.Well, you can have, uh,you can use AI-generated softwares that,you know, they, they measureeverything, but it's still numbers.So if you have artifactssuperimposed to the image, I wouldbe very extremely cautious.So, you know, I wouldcall it abnormal if it's reallyabnormal, but if that also,uh, comes along with abnormal tissuecharacterization on started-- standard sequences,otherwise, I would be cautious.Or, you know, you neverknow.I would report the numberas abnormal, but, uh, clarifying that

there are many artifacts fromdevices because we don't really know.So that's a very goodpoint.There are some new, uh,techniques and new, um, improvements, yes,to, to reduce artifacts inCMR.Yeah.Maybe in the future itwill help us- Maybe in thefuture.Yeah.Yeah.Indeed.

Thank you.So congratulations on the excellent,uh, s- lecture.I would like to askabout your- [laughs] -experience in thefollow-up.As, as you can see,we are all happy having youhere, so e-everyone.Questions.Thank you very much.So kind.

I would like to askyou about the role of theCMR in the follow-up ofthe patients, because now we dohave clear guidelines that theyshow that we should do that.But on the other hand,do we have so much experiencein terms of guiding atherapy?For example, do you seethat patients who have less, um,long-lasting, uh, changes in thefollow-up examinations, do they respond betterto therapy?And do you decide howlong the therapy should last, forexample, for heart failure therapyin those patients based on theCMR results?Thank you very much.

That's a very super interestingquestion.So, um, with regards totreatment, um, what we usually, uh,base, you know, for example,immune suppressive treatment, uh, the decisionto, uh, withdraw it isif you have recovery in LVfunction mainly.So it's something you canachieve with echo.You don't need, um, CMRthat is time-consuming, more expensive.Um, so don't really needthat.

Um, it's useful probably more,uh, for, uh, prognosis, although, uh,to date, um, probably thestrongest predictor of outcome is LVEFat diagnosis, and it doesn'tmatter if you get it withecho or with CMR.Many studies say that ifyou still have edema at follow-up,that means you have ongoinginflammation.That's not a good sign,of course.Um, on the other hand,if you have evidence of LGEpersisting at follow-up, that mostlikely is never going to bereversible.So even if you prolongyour treatment, that's not going to,to change most likely.

So, you know, daily practice,being super practical, what we dois we repeat CMR inpatients that have very extensive lingenhancement.Uh, those that have manysegments involved, um, you know, thosethat have that sort ofring-like pattern, those we tend to,

to follow up.A different issue is forsarcoid.In that case, uh, follow-upimaging is very useful, uh, becauseyou basically base, um, treatmenton the metabolic activity.But a-again, you can dothat with PET because, you know,most patients, you put thedevice in, pacemaker or ICD, andthen the quality of imagesat follow-up is not as goodas what was-- as itwas at the beginning.So PET is probably more,more useful if you want totailor treatment.

I think we, we could,uh, hear you forever.Uh, and, and me personally,I'm, um, I agree with all,all you said.Uh, and we try to,um, to read guidelines, uh, onthe same way, uh, likeyou said, not always just takeeverything what's, what's there, thatwe have to, uh, com-compare itwith the routine clinical practiceand our own, um, own experience.Uh, because as, as weall know, the guidelines, uh, aremostly based on class Crecommendation, so it's still, um, notenough to, to be sureon everything, uh, is there..

If we do not havemore questions, uh- Yeah.The, the...We are also asking aboutthe, uh, treatment.Yes.Uh, so this is likethe common question, um, about thepatients with myocarditis, um, basedon, biopsy-proven myocarditis, um, and,uh, treated with immunosuppression, theimproved ejection fraction.And there is also aquestion if we, uh, still haveto treat those patients withheart fai- heart failure therapy, andhow long?What is your experience in,in Padova?

Yeah.So, uh, what wedo is that, so immune suppress-immune-suppressive treatment comes on topof, um, optimal medical therapy, whichmeans that, uh, if weneed beta blockers, ARnis, SGLT2 inhibitors,we put everything that is,uh, guideline-directed plus immune suppression.So the patient needs tobe treatedproperly and also followed up.Uh, you know, because you,you, you came and you s-you saw we follow ourpatients very closely.So close they don't develop,uh, complications most [chuckles] of times,which is good, I think,in the end.It's, um, um, time-consuming, butit's, uh, effective in the end.But, you know, you shouldapply guideline-directed therapy for heart failure,arrhythmias if the patient hasarrhythmias.And then immune-suppressive treatment is,um, how can I say?

An extra chance that wegive to patients to, um, revertthe history of their disease.But, um, otherwise, they're, um...I think that treating patientwith myocarditis is very, um, challenging,but in a good way.Uh, you have to, um,bear in mind, uh, all yourcardiology knowledge because they mayhave and they may face different,uh, needs, m- you know,heart failure, arrhythmias.Uh, they may develop laterin life coronary artery disease.And so it, it's avery, it's like a 360, uh,degree treatment, and immune suppressionis just one of the pieces.I wouldn't be so sureit could be so effective justtaken alone.

Yeah.So I, I agree, andwe, we do it inthe same, way.So, um, not always relyon, uh, cardiac magnetic resonance.Not always it's necessary, uh,in the, in the follow-up.Uh, but in, in patientsthat we treat immunosuppressively with im-immune suppression, uh, often wedo a control endomyocardial biopsy.And as far as Iremember, your, uh, way, uh,of, taking care ofthese patients is quite similar.

Absolutely, yes.We, we don't repeat endomyocardialbiopsy that often, but we doactually do that if wethink that that might change patient'streatment.So if we see, forexample, a decline in LVF oran increase in arrhythmias duringimmune suppression, then we repeat theendomyocardial biopsy.And we happen to find,for example, that patient had, uh,starting from, um, a autoimmunemyocarditis, under immune suppression they developed,um, viral myocarditis that reverted,uh, all the benefit we couldhave from immune suppression, andthey actually worsen in their LVFand arrhythmias, so we hadto withdraw, um, immune suppression, finding,uh, a lot of viralcopies, uh, in the myocardium.So we act- you know,in selected cases.Um, you know, it's notso easy to get an endomyocardialbiopsy done, and I'm notable to do it myself.Alida's not able, so wehave to ask for help from,from someone else.So in selected cases, werepeat it one time, two time,three times, you know, if,if necessary.

Yeah.So yeah, to, to concludethis s- session, um, thank youagain for, for joiningus.I would like to thankall the, all the speakers.It was a g- reallygreat pleasure for, for us to,to have you all heretoday.And thank you, and Ihope to, to see you again,uh, the next year.Thank you very much forhaving me.Always very kind.Always a pleasure.Thank you.[outro music]