Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) is a relapsing-remitting disease, and immune suppression (IS) is the mainstay of therapy. Predictors of relapse for patients with CS in remission are not well characterized. We assessed incidence of relapse in consecutive patients with CS treated with high-dose steroids and/or steroid-sparing agents (SSA) in our center from 2000 to 2020. Remission was defined as reaching maintenance therapy (no IS, SSA, and/or prednisone ≤5 mg/d) for ≥1 month. Relapse was defined as recurrence of CS syndrome requiring IS intensification: heart failure, ventricular arrhythmia, decrease in left ventricular ejection fraction, or increased disease burden on imaging. Among 68 patients, the mean age was 50.7±9.0 years; 25 (37%) were women, and 32 (47%) were Black. In total, 59 patients (87%) reached remission. Over a median follow-up of 39.5 months (interquartile range 17.6, 92.5), 28 (48%) relapsed. Greater percentage of late gadolinium enhancement (LGE) on pretreatment magnetic resonance imaging corresponded with increased likelihood of relapse (odds ratio 1.396 per 5% increase [95% confidence interval (CI) 1.04 to 1.88]; p = 0.028). LGE ≥11% predicted elevated risk of relapse (adjusted odds ratio 4.998 [1.34 to 18.64]; p = 0.017). Shorter time to relapse was observed with isolated CS (adjusted hazard ratio 4.084 [1.44,11.56]; p = 0.008) and LGE ≥11% (adjusted hazard ratio 3.007 [1.01, 8.98]; p = 0.049). Approximately 1 in 2 patients with CS in remission experienced relapse. Greater burden of LGE on cardiac magnetic resonance imaging and isolated CS are associated with greater risk of relapse. Future work is needed to refine risk stratification for relapse and to optimize surveillance strategies on the basis of the burden of disease.

Myocarditis Presenting as Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) in a Young Man: A Case Report

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a unique disorder that manifests as an acute myocardial infarction clinically without overt coronary arteries obstruction on angiography. Herein, we report a 17-year-old male presented with a chest pain occurring 3 hours before admission and fever lasting for 2 days. Electrocardiogram examination showed ST elevation in lead II, III, aVF and V3-V6. Laboratory tests results showed a normal leukocyte level of 9850/µL, an elevated troponin of 3.55 ng/mL and an elevated quantitative CRP of 46 mg/L. Coronary angiography performed, indicating 20-30% stenosis of the left anterior descending artery, left circumflex artery and right coronary artery, whereas in typical acute myocardial injury, angiography shows >50% coronary stenosis. Additional cardiac MRI examination showed a fulfillment of Lake Louis Criteria for myocarditis, with further findings of acute myocardial edema in the lateral wall of left ventricle, with left ventricle ejection fraction of 59.73%. As researchers are still working on the definition of MINOCA, present knowledge of the causes, pathophysiology, clinical features, or specific phenotypes of MINOCA is also limited. A stepwise diagnostic approach is needed to diagnose MINOCA, with subsequent differential diagnosis exclusion.

[Right ventricle free wall rupture during transcatheter occluder implantation in a patient with postinfarction rupture of the interventricular septum and COVID-19-associated myocarditis. Case report]

Intraventricular septum rupture is a rare mechanic complication of myocardial infarction associated with high mortality. This case describes STEMI in recovered patient after COVID 19 associated pneumonia, which was complicated by ventricular septum rupture followed by cardiogenic shock. It was managed by percutaneous occluder implantation. The procedure was complicated by right ventricular wall rupture. Postmortem examination of myocardium showed the signs of inflammation infiltrate and myocyte necrosis, according to histopathological Dallas criteria diagnosis of COVID-19 associated myocarditis was established. The COVID-19 pandemic has contributed to increasing cardiovascular mortality. This is typically attributed to diminishing resources for timely and appropriate medical care, and patients' late presentations for fear of contracting the infection. Cardiovascular complication of COVID-19 may be another contributing factor. Further research is needed to improve our understanding of the mechanisms and long-term sequelae of myocardium damage in COVID-19, to optimize treatment strategy and subsequent follow-up in such patients.

Use of the Wearable Cardioverter-Defibrillator Among Patients With Myocarditis and Reduced Ejection Fraction or Ventricular Tachyarrhythmia: Data From a Multicenter Registry

Background Data on the use of the wearable cardioverter-defibrillator (WCD) among patients with myocarditis remain sparse. Consequently, evidence for guideline recommendations in this patient population is lacking. Methods and Results In total, 1596 consecutive patients were included in a multicenter registry from 8 European centers, with 124 patients (8%) having received the WCD due to myocarditis and reduced left ventricular ejection fraction or prior ventricular tachyarrhythmia. The mean age was 51.6±16.3 years, with 74% being male. Patients were discharged after index hospitalization on heart failure medication: Angiotensin-converting enzyme inhibitors (62.5%), angiotensin-receptor-neprilysin inhibitor (22.9%), aldosterone-antagonists (51%), or beta blockers (91.4%). The initial median left ventricular ejection fraction was 30% (22%-45%) and increased to 48% (39%-55%) over long-term follow-up (P<0.001). The median BNP (brain natriuretic peptide) level at baseline was 1702 pg/mL (565-3748) and decreased to 188 pg/mL (26-348) over long-term follow-up (P=0.022). The mean wear time was 79.7±52.1 days and 21.0±4.9 hours per day. Arrhythmic event rates documented by the WCD were 9.7% for nonsustained ventricular tachycardia, 6.5% for sustained ventricular tachycardia, and 0% for ventricular fibrillation. Subsequently, 2.4% of patients experienced an appropriate WCD shock. The rate of inappropriate WCD shocks was 0.8%. All 3 patients with appropriate WCD shock had experienced ventricular tachycardia/ventricular fibrillation before WCD prescription, with only 1 patient showing a left ventricular ejection fraction <35%. Conclusions Patients with myocarditis and risk for occurrence of ventricular tachyarrhythmia may benefit from WCD use. Prior ventricular arrhythmia might appear as a better risk predictor than a reduced left ventricular ejection fraction <35% in this population.

Increased reports of severe myocarditis associated with enterovirus infection in neonates, United Kingdom, 27 June 2022 to 26 April 2023

Enteroviruses are a common cause of seasonal childhood infections. The vast majority of enterovirus infections are mild and self-limiting, although neonates can sometimes develop severe disease. Myocarditis is a rare complication of enterovirus infection. Between June 2022 and April 2023, twenty cases of severe neonatal enteroviral myocarditis caused by coxsackie B viruses were reported in the United Kingdom. Sixteen required critical care support and two died. Enterovirus PCR on whole blood was the most sensitive diagnostic test. We describe the initial public health investigation into this cluster and aim to raise awareness among paediatricians, laboratories and public health specialists.

Diagnostic and therapeutic dilemmas in a patient with myocarditis, Brugada syndrome and arrhythmic syncope

We present a case of a previously healthy 23-year-old male who presented with chest pain, palpitations and spontaneous type 1 Brugada electrocardiographic (ECG) pattern. Positive family history for sudden cardiac death (SCD) was remarkable. Initially, clinical symptoms in combination with myocardial enzymes elevation, regional myocardial oedema with late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and inflammatory lymphocytoid-cell infiltrates in the endomyocardial biopsy (EMB) suggested the diagnosis of a myocarditis-induced Brugada phenocopy (BrP). Under immunosuppressive therapy with methylprednisolone and azathioprine, a complete remission of both symptoms and biomarkers was accomplished. However, the Brugada pattern did not resolve. The eventually spontaneous Brugada pattern type 1 established the diagnosis of Brugada syndrome (BrS). Due to his previous history of syncope, the patient was offered an ICD that he declined. After his discharge he experienced a new episode of arrhythmic syncope. He was readmitted and received an ICD.

Fenestrated Fontan-like circulation under durable left-ventricular assist device support in fulminant myocarditis

Fulminant myocarditis is a fatal development from profound biventricular heart failure and often requires both right- and left-ventricular assistance to maintain hemodynamics, even at the risk of increased mortality and morbidity. Here, we present a 42-year-old female with profound biventricular failure due to fulminant myocarditis, resolved by an isolated durable left-ventricular assist device support under a fenestrated, Fontan-like circulation and managed low-pulmonary vascular resistance.

Trans-subclavian approach for Impella CP implantation using the chimney graft in a pediatric patient with fulminant myocarditis during extracorporeal support

Impella is a device effective for the treatment of cardiogenic shock. However, among small children, its application has limitations due to left ventricle size and vasculature and the turning diameter of the aortic arch. Herein, we report an 11-year-old girl with fulminant myocarditis who was successfully managed with Impella CP implantation via the right subclavian artery using a polyethylene terephthalate chimney graft. Compared with insertion via the femoral artery, this method has several advantages. That is, it can address limitations in aortic arch diameter and facilitate equable fixation of the Impella device in small pediatric patients.

Q wave in paediatric myocarditis: an underinvestigated, readily available prognostic factor

BACKGROUND

Myocarditis is an uncommon disease in children with potentially fatal consequences. An electrocardiogram (ECG) change seen in myocarditis is pathological Q wave. Pathological Q wave is linked to permanent damage and myocardial death in several cardiac diseases. We investigated the significance of pathological Q waves in children with acute myocarditis (AM).

METHODS

This retrospective observational study analysed the data of 59 children with AM admitted to our hospital between January 2016 and July 2021. They were divided into Q wave and non-Q wave myocarditis groups. Patients' laboratory data, echocardiography, treatment and hospital outcome were analysed.

RESULTS

Patients were 64.4% male and had a median age of 6 years and 9 months. Pathological Q waves were found in 52.5% of the patients. Q wave myocarditis group had higher troponin I values (499 vs. 145 ng/L, p = 0.011) and longer hospital stays (13 vs. 9 days, p = 0.020) than the non-Q wave group. They also required higher doses of inotropic or vasoactive drugs. 61.3% of Q wave patients needed mechanical ventilation compared to 35.7% of non-Q wave patients (p = 0.069). All the patients who died or discharged with an LVEF < 30% belonged to the Q wave group.

CONCLUSION

Q wave in AM warrants close monitoring and intensive treatment as it accompanies more severe complications and poorer outcomes. This readily available ECG finding can be a clue to prognoses of AM patients. Further research with larger populations is needed to better understand Q wave prognostic accuracy and its potential role in guiding more expensive treatments.

Soluble suppression of tumorigenicity 2 associated with fulminant myocarditis in children: A retrospective observational study

Fulminant myocarditis (FM) is associated with high mortality, and studies on soluble suppression of tumorigenicity 2 (sST2) and myocarditis are still scarce. The aim of this study was to investigate the relationship between sST2 and FM in children with myocarditis. This was a single-center retrospective clinical observational study. We continuously included patients diagnosed as suspected viral myocarditis from December 2019 to December 2022. A total of 203 patients younger than 11 years old were enrolled in this study, 22 of whom were diagnosed with FM. The level of sST2 was positively correlated with N-terminal B-type natriuretic peptide (NT-proBNP) (R = 0.5588, P < .0001). After including multiple factors, creatinine (odd ratio [OR] 0.911; 95% confidence interval [CI], 0.842-0.986; P = .021), NT-proBNP (OR 1.000; 95% CI, 1.000-1.000; P = .01), left ventricular ejection fraction (OR 1.306; 95% CI, 1.153-1.478; P < .001) and sST2 (OR 0.982; 95% CI, 0.965-0.999; P = .038) were still risk factors for FM. The area under curve values were 0.852 for the NT-proBNP, 0.817 for the creatinine, 0.914 for the left ventricular ejection fraction, and 0.865 for the sST2, which showed good sensitivity and specificity for FM. Elevated level of sST2 was associated with fulminant myocarditis. sST2 might be used as a potential biomarker for the diagnosis of fulminant myocarditis.

Immune checkpoint inhibitor-associated myocarditis and fulminant type I diabetes in a patient with metastatic non-small cell lung cancer

A woman in her mid-60s presented to the hospital due to a history of nausea, vomiting, shortness of breath, dyspnoea on exertion and polyuria. She was receiving medical therapy for advanced non-small cell lung cancer and recently initiated immune checkpoint inhibitor (ICI) immunotherapy. Investigations revealed lab results consistent with diabetic ketoacidosis (DKA), elevated cardiac biomarkers, multiple cardiac arrhythmias and reduced ejection fraction on transthoracic echocardiogram. Cardiac catheterisation showed non-obstructive coronary arteries.The patient was diagnosed with an ICI-associated myocarditis and type I diabetes due to recent initiation of the ICI durvalumab. She was treated with the institutional DKA protocol and received corticosteroid therapy for drug toxicity according to guidelines. She was discharged with marked improvement in symptoms. The patient had good recovery after discharge with further investigations showing improvement in her cardiac ejection fraction on cardiac MRI. She remains on medical therapy with an insulin regimen for diabetes management.

Improved outcomes with early immunosuppression in patients with immune-checkpoint inhibitor induced myasthenia gravis, myocarditis and myositis: a case series

PURPOSE

Myasthenia gravis (MG) is a rare but life-threatening complication of immune-checkpoint inhibitor (ICI) therapy and often co-presents with myositis and myocarditis. Previous case series of ICI-related MG have reported high mortality rates. We present a series of ten patients from a tertiary oncology centre outlining outcomes of an early multi-modal immunosuppression strategy.

METHODS

We reviewed The Christie Hospital database of immunotherapy-related toxicity from 2017 to 2020. Symptom severity was assessed using the Myasthenia Gravis Foundation of America (MGFA) classification.

RESULTS

Ten patients with ICI-related MG were identified. All patients presented following 1 (n = 4) or 2 (n = 6) cycles of ICI. Symptom progression was rapid with a median of 3 days from onset of symptoms to admission. Concomitant myositis and myocarditis were observed in nine patients. AChR or MuSK autoantibodies were positive in six patients. All patients received urgent treatment with intravenous methylprednisolone (IVMP) and eight received intravenous immunoglobulin (IVIG). A single patient died from myasthenia-related symptoms; the remaining 9 patients were successfully discharged.

CONCLUSION

In our cohort, we demonstrate good outcomes associated with early intensive immunosuppressive treatment with IVIG and IVMP. An agreed national treatment protocol or clinical discussion forum would be beneficial.

Treatment strategy for acute myocarditis in pediatric patients requiring emergency intervention

BACKGROUND

Patients with acute myocarditis present with a wide range of symptoms. Treatment strategies for pediatric patients with circulatory failure comprise extracorporeal membrane oxygenation (ECMO), emergency temporary pacing, and pharmacotherapy. However, they remain controversial. ECMO is an effective treatment but gives rise to several complications; the goal is therefore to avoid excessive treatment as much as possible. We aimed to evaluate the importance of electrocardiogram findings in differentiating severity and establish an appropriate treatment strategy in pediatric patients with acute myocarditis who required emergency interventions.

METHODS

This retrospective study enrolled pediatric patients admitted to and treated in our hospital for acute myocarditis between April 1983 and December 2021. Patients were retrospectively divided into whether circulatory failure occurred (ECMO or temporary pacing was needed; emergency intervention group) or not (pharmacotherapy alone).

RESULTS

Of the 26 pediatric patients, 11 experienced circulatory failure while 15 did not. In the circulatory failure group, six patients were treated with ECMO (ECMO group) and five patients with temporary pacing (pacing group). In the pacing group, all patients were diagnosed with complete and/or advanced atrioventricular block (CAVB and/or advanced AVB) and narrow QRS. Furthermore, these patients improved only with temporary pacing and pharmacotherapy, without requiring ECMO. Wide QRS complexes (QRS ≥ 0.12 ms) with ST-segment changes were detected on admission in five of six patients in the ECMO group and none in the pacing group (P = 0.015). Although all patients in the ECMO group experienced complications, none did in the pacing group (P < 0.008).

CONCLUSIONS

Regarding emergency intervention for acute myocarditis, ECMO or temporary pacing could be determined based on electrocardiogram findings, particularly wide QRS complexes with ST-segment changes on admission. It is important to promptly introduce ECMO in patients with wide QRS complexes with ST-segment changes, however, patients with CAVB and/or advanced AVB and narrow QRS could improve without undergoing ECMO. Therefore, excessive treatment should be avoided by separating ECMO from temporary pacing based on electrocardiogram findings on admission.

"Function follows form": Role of cardiac magnetic resonance for ventricular arrhythmia risk stratification in patients with cardiac sarcoidosis

INTRODUCTION

Cardiac involvement is common and may become clinically relevant in approximately 5%-10% of patients with systemic sarcoidosis. Although reduced left ventricular ejection fraction is a recognized predictor of mortality, recent studies have suggested an increased risk of ventricular arrhythmia (VAs) and sudden cardiac death (SCD) in patients with cardiac sarcoidosis (CS) and evidence of late gadolinium enhancement-cardiac magnetic resonance (LGE-CMR), irrespective of the underlying left ventricular systolic function. We performed a meta-analysis to assess the correlation between VAs/SCD and presence of LGE-CMR in CS patients.

METHODS

We systematically searched Medline, Embase, and Cochrane electronic databases up to January 2, 2023, for studies enrolling patients with suspected or confirmed CS undergoing LGE-CMR. Clinical outcomes of interest included clinically relevant VAs, defined as sustained ventricular tachycardia, ventricular fibrillation, SCD, or aborted SCD during follow-up. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI).

RESULTS

A total of 14 studies fulfilled the selection criteria and were included in the final analysis. Among 1273 patients, LGE was detected in 465 (36.5%; Group LGE+). Males accounted for 45.2% (95% CI: 40.5%-55.7%) of the total population and the average age was 56.8 (95% CI: 52.7%-60.9) years. A total of 104 (22.3%) of 465 LGE+ patients experienced a clinically relevant VA, compared to 6 (0.7%) of 808 LGE- ones. LGE+ was associated with a ninefold increased risk in life-threatening VAs (22.3% vs. 0.7%; RR = 9.52; 95% CI [5.18-17.49]; p < .0001) compared to patients without LGE (heterogeneity I2  = 0%).

CONCLUSION

In our meta-analysis, LGE+ in patients with CS was associated with a ninefold increased risk in life-threatening VAs compared to patients without LGE.

Sex and Race Differences in Cardiac Sarcoidosis Presentation, Treatment and Outcomes

BACKGROUND

Although sex- and race-based patterns have been described in the extracardiac organ involvement of sarcoidosis, cardiac sarcoidosis (CS)-specific studies are lacking.

METHODS

We studied CS presentation, treatment and outcomes based on sex and race in a tertiary-center cohort. Multivariable adjusted Cox proportional hazards and survival analyses were performed for primary composite outcomes (left ventricular assist device, heart transplantation, all-cause death) and for secondary outcomes (ventricular arrhythmia and all-cause death.

RESULTS

We identified 252 patients with CS (108 female, 109 Black). At presentation with CS, females vs males (P = 0.001) and Black vs White individuals (P = 0.001) more commonly had symptomatic heart failure (HF), with HF most common in Black females (ANOVA P < 0.001). Treatment differences included more corticosteroid use (90% vs 79%; P = 0.020), higher 1-year prednisone dosage (13 vs 10 mg; P = 0.003) and less frequent early steroid-sparing agent use in males (29% vs 40%; P = 0.05). Black participants more frequently received a steroid-sparing agent (75% vs 60%; P = 0.023). Composite outcome-free survival did not differ by sex or race. Male sex had an adjusted hazard ratio of 2.34 (95% CI 1.13, 4.80; P = 0.021) for ventricular arrhythmia.

CONCLUSION

CS course may differ by sex and race and may contribute to distinct clinical CS phenotypes.

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

Myocardial recovery in children supported with a durable ventricular assist device-a systematic review

OBJECTIVES

A small percentage of paediatric patients supported with a ventricular assist device (VAD) can have their device explanted following myocardial recovery. The goal of this systematic review is to summarize the current literature on the clinical course in these children after weaning.

METHODS

A systematic literature search was performed on 27 May 2022 using Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar to include all literature on paediatric patients supported by a durable VAD during the last decade. Overlapping study cohorts and registry-based studies were filtered out.

RESULTS

Thirty-seven articles were included. Eighteen of them reported on the incidence of recovery in cohort studies, with an overall incidence rate of 8.7% (81/928). Twenty-two of the included articles reported on clinical outcomes after VAD explantation (83 patients). The aetiologies varied widely and were not limited to diseases with a natural transient course like myocarditis. Most of the patients in the included studies (70; 84.3%) were supported by a Berlin Heart EXCOR, and in 66.3% (55/83), only the left ventricle had to be supported. The longest follow-up period was 19.1 years, and multiple studies reported on long-term myocardial recovery. Fewer than half of the reported deaths had a cardiac cause.

CONCLUSIONS

Myocardial recovery during VAD support is dependent on various contributing components. The interactions among patient-, device-, time- and hospital-related factors are complex and not yet fully understood. Long-term recovery after VAD support is achievable, even after a long duration of VAD support, and even in patients with aetiologies different from myocarditis or post-cardiotomy heart failure. More research is needed on this favourable outcome after VAD support.

Prednisone vs methotrexate in treatment naïve cardiac sarcoidosis

BACKGROUND

Side effects limit the long-term use of glucocorticoids in cardiac sarcoidosis (CS), and methotrexate has gained attention as steroid sparing agent although the supporting evidence is poor. This study compared prednisone monotherapy, methotrexate monotherapy or a combination of both, in the reduction of myocardial Fluorine-18 fluorodeoxyglucose (FDG) uptake and clinical stabilization of CS patients.

METHODS AND RESULTS

In this retrospective cohort study, 61 newly diagnosed and treatment naïve CS patients commenced treatment with prednisone (N = 21), methotrexate (N = 30) or prednisone and methotrexate (N = 10) between January 2010 and December 2017. Primary outcome was metabolic response on FDG PET/CT and secondary outcomes were treatment patterns, major adverse cardiovascular events, left ventricular ejection fraction, biomarkers and side effects. At a median treatment duration of 6.2 [5.7-7.2] months, 71.4% of patients were FDG PET/CT responders, and the overall myocardial maximum standardized uptake value decreased from 6.9 [5.0-10.1] to 3.4 [2.1-4.7] (P < 0.001), with no significant differences between treatment groups. During 24 months of follow-up, 7 patients (33.3%; prednisone), 6 patients (20.0%; methotrexate) and 1 patient (10.0%; combination group) experienced at least one major adverse cardiovascular event (P = 0.292). Left ventricular ejection fraction was preserved in all treatment groups.

CONCLUSIONS

Significant suppression of cardiac FDG uptake occurred in CS patients after 6 months of prednisone, methotrexate or combination therapy. There were no significant differences in clinical outcomes during follow-up. These results warrant further investigation of methotrexate treatment in CS patients.

Sex and age differences in AMPK phosphorylation, mitochondrial homeostasis, and inflammation in hearts from inflammatory cardiomyopathy patients

Linked to exacerbated inflammation, myocarditis is a cardiovascular disease, which may lead to dilated cardiomyopathy. Although sex and age differences in the development of chronic myocarditis have been postulated, underlying cellular mechanisms remain poorly understood. In the current study, we aimed to investigate sex and age differences in mitochondrial homeostasis, inflammation, and cellular senescence. Cardiac tissue samples from younger and older patients with inflammatory dilated cardiomyopathy (DCMI) were used. The expression of Sirt1, phosphorylated AMPK, PGC-1α, Sirt3, acetylated SOD2, catalase, and several mitochondrial genes was analyzed to assess mitochondrial homeostasis. The expression of NF-κB, TLR4, and interleukins was used to examine the inflammatory state in the heart. Finally, several senescence markers and telomere length were investigated. Cardiac AMPK expression and phosphorylation were significantly elevated in male DCMI patients, whereas Sirt1 expression remained unchanged in all groups investigated. AMPK upregulation was accompanied by a preserved expression of all mitochondrial proteins/genes investigated in older male DCMI patients, whereas the expression of TOM40, TIM23, and the mitochondrial oxidative phosphorylation genes was significantly reduced in older female patients. Mitochondrial homeostasis in older male patients was further supported by the reduced acetylation of mitochondrial proteins as indicated by acetylated SOD2. The inflammatory markers NF-κB and TLR4 were downregulated in older male DCMI patients, whereas the expression of IL-18 was increased in older female patients. This was accompanied by progressed senescence in older DCMI hearts. In conclusion, older women experience more dramatic immunometabolic disorders on the cellular level than older men.

A case of fatal multi-organ inflammation following COVID-19 vaccination

A 14-year-old Japanese girl died unexpectedly 2 days after receiving the third dose of the BNT1262b2 mRNA COVID-19 vaccine. Autopsy findings showed congestive edema of the lungs, T-cell lymphocytic and macrophage infiltration in the lungs, pericardium, and myocardium of the left atria and left ventricle, liver, kidneys, stomach, duodenum, bladder, and diaphragm. Since there was no preceding infection, allergy, or drug toxicity exposure, the patient was diagnosed with post-vaccination pneumonia, myopericarditis, hepatitis, nephritis, gastroenteritis, cystitis, and myositis. Although neither type of inflammation is fatal by itself, arrhythmia is reported to be the most common cause of death in patients with atrial myopericarditis. In the present case, arrhythmia of atrial origin was assumed as the cause of cardiac failure and death. In sudden post-vaccination deaths, aggressive autopsy systemic search and histological examination involving extensive sectioning of the heart, including the atrium, are indispensable.

Heart transplantation in end-stage heart failure secondary to cardiac sarcoidosis: an updated systematic review

The prevalence of cardiac sarcoidosis is increasing with improved cardiac imaging and may lead to severe heart failure, cardiomyopathy, and arrhythmias that warrant heart transplant consideration. This study aimed to evaluate the outcomes of heart transplantation in sarcoidosis. We systematically searched PubMed/MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. We identified 15 articles that examined patients with cardiac sarcoidosis. The study aimed to evaluate the outcomes of heart transplantation in cardiac sarcoidosis. We systematically searched EMBASE, PubMed/MEDLINE, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We identified 15 studies that examined 1075 patients with cardiac sarcoidosis who underwent heart transplantation. A total of five studies reported individual patient data. Forty-two patients have been pooled for further analysis. There were 22 male patients, 14 female patients, and 7 patients whose gender was not reported. Among these patients, 10 patients had concomitant pulmonary sarcoidosis at the time of diagnosis. The mean survival was reported for all 42 patients. The mean survival in months was 71.4 months, with a range of 2 days to 288 months. Three patients died of graft failure, 2 patients from septic shock, 2 patients from pneumonia, 1 patient from cervical cancer, and 1 patient from sudden cardiac death. One patient developed a malignant arrythmia in the setting of CMV myocarditis post-heart transplant. Sarcoidosis recurrence after heart transplant was reported in 3 of 30 patients..Patients with cardiac sarcoidosis have shown to have favorable outcomes after heart transplant. Despite these outcomes, some centers still hesitate to pursue heart transplant for CS patients. Carefully selected patients with advanced-stage heart failure due to cardiac sarcoidosis have encouraging outcomes after transplantation. Further studies will be needed to evaluate the outcomes of heart transplantation in sarcoidosis.

Campylobacter myocarditis: a rare but potential sequelae of Campylobacter jejuni

Myocarditis is an inflammatory cardiomyopathy with a diverse range of both infective and non-infective causes. It is an important cause of dilated cardiomyopathy worldwide, with a variable clinical course ranging from a mild self-limiting illness to fulminant cardiogenic shock requiring mechanical circulatory support and cardiac transplantation. Here, we describe a case of acute myocarditis secondary to Campylobacter jejuni infection in a man in his 50s who presented with an acute coronary syndrome following a recent gastrointestinal illness.

Low T3 syndrome is associated with 30-day mortality in adult patients with fulminant myocarditis

Background

Fulminant myocarditis (FM) is a critical disease with high early mortality. Low triiodothyronine syndrome (LT3S) was a strong predictor of poor prognosis of critical diseases. This study investigated whether LT3S was associated with 30-day mortality in FM patients.

Methods

Ninety-six FM patients were divided into LT3S (n=39, 40%) and normal free triiodothyronine (FT3) (n=57, 60%) groups based on serum FT3 level. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. Kaplan-Meier curve was used to compare 30-day mortality between two groups. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to assess the value of FT3 level for 30-day mortality prediction.

Results

Compared to normal FT3 group, LT3S group had higher incidence of ventricular arrhythmias, worse hemodynamics, worse cardiac function, more severe kidney impairment, and higher 30-day mortality (48.7% vs. 12.3%, P<0.001). In univariable analysis, LT3S (odds ratio [OR]:6.786, 95% confidence interval [CI]:2.472-18.629, P<0.001) and serum FT3 (OR:0.272, 95%CI:0.139-0.532, P<0.001) were significant strong predictors of 30-day mortality. After adjustment for confounders in multivariable analysis, LT3S (OR:3.409, 95%CI:1.019-11.413, P=0.047) and serum FT3 (OR:0.408, 95%CI:0.199-0.837, P=0.014) remained independent 30-day mortality predictors. The area under the ROC curve of FT3 level was 0.774 (cut-off: 3.58, sensitivity: 88.46%, specificity: 62.86%). In DCA, FT3 level showed good clinical-application value for 30-day mortality prediction.

Conclusion

In FM patients, LT3S could independently predict 30-day mortality. FT3 level was a strong 30-day mortality predictor and a potentially useful risk-stratification biomarker.