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Trends in myocarditis incidence, complications and mortality in Sweden from 2000 to 2014. Sci Rep 2022; 12:1810. [PMID: 35110692 PMCID: PMC8810766 DOI: 10.1038/s41598-022-05951-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/13/2022] [Indexed: 12/12/2022] Open
Abstract
Investigate trends in myocarditis incidence and prognosis in Sweden during 2000–2014. Little data exist concerning population-trends in incidence of hospitalizations for myocarditis and subsequent prognosis. Linking Swedish National Patient and Cause of Death Registers, we identified individuals ≥ 16 years with first-time diagnosis of myocarditis during 2000–2014. Reference population, matched for age and birth year (n = 16,622) was selected from Swedish Total Population Register. Among the 8 679 cases (75% men, 64% < 50 years), incidence rate/100,000 inhabitants rose from 6.3 to 8.6 per 100,000, mostly in men and those < 50 years. Incident heart failure/dilated cardiomyopathy occurred in 6.2% within 1 year after index hospitalization and in 10.2% during 2000–2014, predominantly in those ≥ 50 years (12.1% within 1 year, 20.8% during 2000–2014). In all 8.1% died within 1 year, 0.9% (< 50 years) and 20.8% (≥ 50 years). Hazard ratios (adjusted for age, sex) for 1-year mortality comparing cases and controls were 4.00 (95% confidence interval 1.37–11.70), 4.48 (2.57–7.82), 4.57 (3.31–6.31) and 3.93 (3.39–4.57) for individuals aged < 30, 30 to < 50, 50 to < 70, and ≥ 70 years, respectively. The incidence of myocarditis during 2000–2014 increased, predominantly in men < 50 years. One-year mortality was low, but fourfold higher compared with reference population.
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The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12010156. [PMID: 35054323 PMCID: PMC8774755 DOI: 10.3390/diagnostics12010156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is used to investigate suspected acute myocarditis, however most supporting data is retrospective and few studies have included parametric mapping. We aimed to investigate the utility of contemporary multiparametric CMR in a large prospective cohort of patients with suspected acute myocarditis, the impact of real-world variations in practice, the relationship between clinical characteristics and CMR findings and factors predicting outcome. 540 consecutive patients we recruited. The 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation were followed-up for 674 (504–915) days. 39 patients underwent follow-up CMR at 189 (166–209) days. CMR provided a positive diagnosis in 72% of patients, including myocarditis (40%) and myocardial infarction (11%). In multivariable analysis, male sex and shorter presentation-to-scan interval were associated with a diagnosis of myocarditis. Presentation with heart failure (HF) was associated with lower left ventricular ejection fraction (LVEF), higher LGE burden and higher extracellular volume fraction. Lower baseline LVEF predicted follow-up LV dysfunction. Multiparametric CMR has a high diagnostic yield in suspected acute myocarditis. CMR should be performed early and include parametric mapping. Patients presenting with HF and reduced LVEF require closer follow-up while those with normal CMR may not require it.
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Molecular Mechanisms behind Persistent Presence of Parvovirus B19 in Human Dilated Myocardium. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1376:181-202. [DOI: 10.1007/5584_2021_702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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54
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Chaligne C, Mageau A, Ducrocq G, Ou P, Alexandra JF, Mutuon P, Papo T, Sacre K. Acute myocarditis revealing autoimmune and inflammatory disorders: Clinical presentation and outcome. Int J Cardiol 2021; 351:84-88. [PMID: 34979146 DOI: 10.1016/j.ijcard.2021.12.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Acute myocarditis (AM) may be the heralding manifestation of autoimmune and inflammatory disorders (AIID). We aimed to describe the clinical presentation and outcome of patients with AM revealing AIID. METHODS All consecutive adult patients with AM admitted in a department of Cardiology (Bichat Hospital, Paris, France) from January 2011 to January 2019 were included. Diagnosis of AM was based on clinical manifestations, elevated Troponin, myocardial inflammation on CMR and no evidence for coronary artery disease. AIID were classified using international criteria. RESULTS Two-hundred and eighteen (35.3 [26.4-47.1] years, 75.2% males) patients with AM were included. Overall, AM revealed AIID in 15 (6.9%), including systemic lupus erythematosus (n = 3), adult onset Still's disease (n = 3), sarcoidosis (n = 2), mixed connective tissue disease (n = 1), anti-Jo1 syndrome (n = 1), eosinophilic granulomatosis with polyangiitis (n = 1), antiphospholipid syndrome (n = 1), reactive arthritis (n = 1), Graves' disease (n = 1) and Crohn's colitis (n = 1). Left ventricular ejection fraction (LVEF) at onset was <30% in 5 (33.3%) patients with AIID. All but 2 patients with AIID were treated with steroids, immunosuppressive and/or immunomodulatory drugs and LVEF normalized in all by the end of follow-up. By comparing patients with AIID to patients with idiopathic AM (n = 203), multivariable analysis showed that pericardial effusion, lack of chest pain and high CRP level at onset were independently associated with AIID. CONCLUSION Acute myocarditis revealing AIID may be life-threatening at the acute phase but has an overall good prognosis under specific treatment. Pericardial effusion and CRP level at admission suggest an AIID as the cause for AM.
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Affiliation(s)
- Camille Chaligne
- Département de Médecine Interne, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Arthur Mageau
- Département de Médecine Interne, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Phalla Ou
- Département de Radiologie, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jean-Francois Alexandra
- Département de Médecine Interne, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Pierre Mutuon
- Département d'Information Médicale, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U1149, Paris, France
| | - Karim Sacre
- Département de Médecine Interne, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U1149, Paris, France.
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55
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Hu Y, Ren J, Dong X, Zhang D, Qu Y, Yang C, Sun Y, Li J, Luo F, Wang W, Wang H, Qing P, Zhao S, Huang J, Yu L, Liu Y, Tan H. Fulminant Giant Cell Myocarditis vs. Lymphocytic Myocarditis: A Comparison of Their Clinical Characteristics, Treatments, and Outcomes. Front Cardiovasc Med 2021; 8:770549. [PMID: 34926619 PMCID: PMC8678080 DOI: 10.3389/fcvm.2021.770549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives: Fulminant myocarditis (FM) is a rapidly progressive and frequently fatal form of myocarditis that has been difficult to classify. This study aims to compare the clinical characteristics, treatments and outcomes in patients with fulminant giant cell myocarditis (FGCM) and fulminant lymphocytic myocarditis (FLM). Methods and Results: In our retrospective study, nine patients with FGCM (mean age 47.9 ± 7.5 years, six female) and 7 FLM (mean age 42.1 ± 12.3 years, four female) patients confirmed by histology in the last 11 years were included. Most patients with FGCM and FLM were NYHA functional class IV (56 vs. 100%, p = 0.132). Patients with FGCM had significantly lower levels of high-sensitivity C-reactive protein [hs-CRP, 4.4 (2.0–10.2) mg/L vs. 13.6 (12.6–14.6) mg/L, P = 0.004, data shown as the median with IQR], creatine kinase-myoglobin [CK-MB, 1.4 (1.0–3.2) ng/ml vs. 14.6 (3.0–64.9) ng/ml, P = 0.025, median with IQR], and alanine aminotransferase [ALT, 38.0 (25.0–61.5) IU/L vs. 997.0 (50.0–3,080.0) IU/L, P = 0.030, median with IQR] and greater right ventricular end-diastolic diameter (RVEDD) [2.9 ± 0.3 cm vs. 2.4 ± 0.6 cm, P = 0.034, mean ± SD] than those with FLM. No differences were observed in the use of intra-aortic balloon pump (44 vs. 43%, p = 1.000) and extracorporeal membrane oxygenation (11 vs. 43%, p = 0.262) between the two groups. The long-term survival rate was significantly lower in FGCM group compared with FLM group (0 vs. 71.4%, p = 0.022). A multivariate cox regression analysis showed the level of hs-CRP (hazard ratio = 0.871, 95% confidence interval: 0.761–0.996, P = 0.043) was an independent prognostic factor for FM patients. Furthermore, the level of hs-CRP had a good ability to discriminate between patients with FGCM and FLM (AUC = 0.94, 95% confidence interval: 0.4213–0.9964). Conclusions: The inflammatory response and myocardial damage in the patients with FGCM were milder than those with FLM. Patients with FGCM had distinctly poorer prognoses compared with those with FLM. Our results suggest that hs-CRP could be a promising prognostic biomarker and a hs-CRP level of 11.71 mg/L is an appropriate cutoff point for the differentiating diagnosis between patients with FGCM and FLM.
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Affiliation(s)
- Yuxiao Hu
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jie Ren
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xueqi Dong
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Di Zhang
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yi Qu
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chunxue Yang
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Sun
- Department of Pathology, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jinghui Li
- Magnetic Resonance Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fang Luo
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wei Wang
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Huanhuan Wang
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ping Qing
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Magnetic Resonance Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jie Huang
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Litian Yu
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yaxin Liu
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Huiqiong Tan
- Emergency and Critical Care Center, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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56
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Huang X, Gao Y, Hua F, Ying J. Differential Diagnosis of Fulminant Myocarditis and Acute Coronary Syndromes in the Case of Failure of Coronary Angiography: A Case Report. Front Cardiovasc Med 2021; 8:690974. [PMID: 34917653 PMCID: PMC8669105 DOI: 10.3389/fcvm.2021.690974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Fulminant myocarditis (FM) is a severe disease with a rapidly progressive and life-threatening course caused mainly by viral infection. The symptoms, laboratory findings, and presence of ECG changes resemble acute coronary syndrome. Therefore, coronary angiography is usually helpful in making the appropriate diagnosis. However, failure to obtain complete coronary artery images due to coronary artery anatomic variations poses a challenge for the diagnosis of FM. Here, we report a case of FM preliminarily diagnosed as acute coronary syndrome (ACS) due to the presence of coronary artery anomaly.
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Affiliation(s)
- Xiangfei Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Yi Gao
- Department of Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fuzhou Hua
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Jun Ying
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
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57
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Affiliation(s)
- Melina Müller
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Leslie T Cooper
- Department of Cardiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bettina Heidecker
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
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58
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Li S, Duan X, Feng G, Sirajuddin A, Yin G, Zhuang B, He J, Xu J, Yang W, Wu W, Sun X, Zhao S, Wang H, Teng Z, Lu M. Multiparametric Cardiovascular Magnetic Resonance in Acute Myocarditis: Comparison of 2009 and 2018 Lake Louise Criteria With Endomyocardial Biopsy Confirmation. Front Cardiovasc Med 2021; 8:739892. [PMID: 34712710 PMCID: PMC8545987 DOI: 10.3389/fcvm.2021.739892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/10/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Cardiac magnetic resonance (CMR) has been shown to improve the diagnosis of myocarditis, but no systematic comparison of this technique is currently available. The purpose of this study was to compare the 2009 and 2018 Lake Louise Criteria (LLC) for the diagnosis of acute myocarditis using 3.0 T MRI with endomyocardial biopsy (EMB) as a reference and to provide the cutoff values for multiparametric CMR techniques. Methods: A total of 73 patients (32 ± 14 years, 71.2% men) with clinically suspected myocarditis undergoing EMB and CMR with 3.0 T were enrolled in the study. Patients were divided into two groups according to EMB results (EMB-positive and -negative groups). The CMR protocol consisted of cine-SSFP, T2 STIR, T2 mapping, early and late gadolinium enhancement (EGE, LGE), and pre- and post-contrast T1 mapping. Their potential diagnostic ability was assessed with receiver operating characteristic curves. Results: The myocardial T1 and T2 relaxation times were significantly higher in the EMB-positive group than in the EMB-negative group. Optimal cutoff values were 1,228 ms for T1 relaxation times and 58.5 ms for T2 relaxation times with sensitivities of 86.0 and 83.7% and specificities of 93.3 and 93.3%, respectively. The 2018 LLC had a better diagnostic performance than the 2009 LLC in terms of sensitivity, specificity, positive predictive value, and negative predictive value. T1 mapping + T2 mapping had the largest area under the curve (0.95) compared to other single or combined parameters (2018 LLC: 0.91; 2009 LLC: 0.76; T2 ratio: 0.71; EGEr: 0.67; LGE: 0.73; ). The diagnostic accuracy for the 2018 LLC was the highest (91.8%), followed by T1 mapping (89.0%) and T2 mapping (87.7%). Conclusion: Emerging technologies such as T1/ T2 mapping have significantly improved the diagnostic performance of CMR for the diagnosis of acute myocarditis. The 2018 LLC provided the overall best diagnostic performance in acute myocarditis compared to other single standard CMR parameters or combined parameters. There was no significant gain when 2018LLC is combined with the EGE sequence.
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Affiliation(s)
- Shuang Li
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuejing Duan
- State Key Laboratory of Cardiovascular Disease, Department of Pathology, Fuwai Hospital, Beijing, China
| | - Guangxun Feng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, Beijing, China
| | - Arlene Sirajuddin
- Department of Health and Human Services, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Gang Yin
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China
| | - Baiyan Zhuang
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian He
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Xu
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenjing Yang
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weichun Wu
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Department of Echocardiography, Fuwai Hospital, Beijing, China
| | - Xiaoxin Sun
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Department of Nuclear Medicine, Fuwai Hospital, Beijing, China
| | - Shihua Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyue Wang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, Beijing, China
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Minjie Lu
- State Key Laboratory of Cardiovascular Disease, Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China
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59
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Takakuma A, Nishii M, Valaperti A, Hiraga H, Saji R, Sakai K, Matsumura R, Miyata Y, Oba N, Nunose F, Ogawa F, Tamura K, Takeuchi I. Prostaglandin-E2 receptor-4 stimulant rescues cardiac malfunction during myocarditis and protects the heart from adverse ventricular remodeling after myocarditis. Sci Rep 2021; 11:20961. [PMID: 34702968 PMCID: PMC8548292 DOI: 10.1038/s41598-021-99930-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
Cardioprotective effect of prostaglandin-E2 receptor-4 (EP4) stimulation on the ischemic heart has been demonstrated. Its effect on the heart affected by myocarditis, however, remains uncertain. In this study, we investigated therapeutic effect of EP4 stimulant using a mouse model of autoimmune myocarditis (EAM) that progresses to dilated cardiomyopathy (DCM). EP4 was present in the hearts of EAM mice. Treatment with EP4 agonist (ONO-0260164: 20 mg/kg/day) improved an impaired left ventricular (LV) contractility and reduction of blood pressure on day 21, a peak myocardial inflammation. Alternatively, DCM phenotype, characterized by LV dilation, LV systolic dysfunction, and collagen deposition, was observed on day 56, along with activation of matrix metalloproteinase (MMP)-2 critical for myocardial extracellular matrix disruption, indicating an important molecular mechanism underlying adverse ventricular remodeling after myocarditis. Continued treatment with ONO-0260164 alleviated the DCM phenotype, but this effect was counteracted by its combination with a EP4 antagonist. Moreover, ONO-0260164 inhibited in vivo proteolytic activity of MMP-2 in association with up-regulation of tissue inhibitor of metalloproteinase (TIMP)-3. EP4 stimulant may be a promising and novel therapeutic agent that rescues cardiac malfunction during myocarditis and prevents adverse ventricular remodeling after myocarditis by promoting the TIMP-3/MMP-2 axis.
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Affiliation(s)
- Akira Takakuma
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Mototsugu Nishii
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004.
| | - Alan Valaperti
- Department of Immunology, University Hospital Zurich, Schmelzbergstrasse 26, CH-8091, Zurich, Switzerland
| | - Haruto Hiraga
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Ryo Saji
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Kazuya Sakai
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Reo Matsumura
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Yasuo Miyata
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Nozomu Oba
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Fumiya Nunose
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Fumihiro Ogawa
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan, 236-0004
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60
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MicroRNA-324-3p Plays A Protective Role Against Coxsackievirus B3-Induced Viral Myocarditis. Virol Sin 2021; 36:1585-1599. [PMID: 34632544 DOI: 10.1007/s12250-021-00441-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/28/2021] [Indexed: 02/05/2023] Open
Abstract
Viral myocarditis (VM) is an inflammatory disease of the myocardium associated with heart failure, which is caused by common viral infections. A majority of the infections are initiated by coxsackievirus B3 (CVB3). MicroRNAs (miRNAs) have a major role in various biological processes, including gene expression, cell growth, proliferation, and apoptosis, as well as viral infection and antiviral immune responses. Although, miRNAs have been found to regulate viral infections, their role in CVB3 infection remains poorly understood. In the previous study, miRNA microarray results showed that miR-324-3p expression levels were significantly increased when cells and mice were infected with CVB3. It was also found that miR-324-3p downregulated TRIM27 and decreased CVB3 replication in vitro and in vivo. In vitro, analysis of downstream signaling of TRIM27 revealed that, miR-324-3p inhibited CVB3 infection, and reduced cytopathic effect and viral plaque formation by reducing the expression of TRIM27. In vivo, miR-324-3p decreased the expression of TRIM27, reduced cardiac viral replication and load, thereby strongly attenuating cardiac injury and inflammation. Taken together, this study suggests that miR-324-3p targets TRIM27 to inhibit CVB3 replication and viral load, thereby reducing the cardiac injury associated with VM.
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61
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Zhao F, Shi G, Wu Z, Guo Z. A successful rescue of juvenile fulminant myocarditis by extracorporeal membrane oxygenation combined with intra-aortic balloon pump: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1355. [PMID: 34532492 PMCID: PMC8422090 DOI: 10.21037/atm-21-3959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022]
Abstract
Myocarditis refers to myocardial inflammatory damage, and it can have various causes. Myocarditis can lead to impaired cardiac function, including decreased systolic and diastolic function and arrhythmia. When myocarditis occurs suddenly and rapidly progresses to severe heart failure, hypotension, cardiogenic shock, or severe arrhythmia, it can be diagnosed as fulminant myocarditis (FM). Our hospital recently admitted a case of juvenile FM, a 17-year-old male, who was admitted to the hospital for “intermittent chest tightness and asthma for 10 days”. When the patient was hospitalized, he complained of chest tightness, palpitation, shortness of breath, fatigue, and dyspnea. Wet rales could be heard in both lungs on auscultation, as well as arrhythmia. Echocardiograms indicated an ejection fraction of 10%. Laboratory tests showed liver and kidney dysfunction as well as abnormal coagulation function. After admission, he was treated with drugs including cardiotonic, diuretic, hormonal, antiviral drugs, and drugs affecting immune regulation. After tracheal intubation-assisted ventilation, the patient’s symptoms did not significantly alleviate, and then veno-arterial extracorporeal membrane oxygenation (V-A ECMO) combined with an intra-aortic balloon pump (IABP) were used to assist in the treatment of cardiopulmonary failure. After the treatment, the patient’s hemodynamics were stable, the respiratory and circulatory functions were restored, and the ECMO and IABP were successfully removed. The patient’s review results were satisfactory, and he was discharged without delay. Although ECMO has no direct therapeutic effect on myocarditis, it can quickly stabilize hemodynamics, improve systemic tissue perfusion, reduce the use of high-dose vasoactive drugs and effectively assist patients during the acute phase of myocarditis. The authors believe that ECMO is the first choice for the treatment of FM in adolescents. Here we summarize our experience at our hospital with the treatment of FM using life support methods.
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Affiliation(s)
- Feng Zhao
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Guoning Shi
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Zhenhua Wu
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Zhigang Guo
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, China
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Krasic S, Prijic S, Ninic S, Nesic D, Bjelakovic B, Petrovic G, Cerovic I, Vukomanovic V. Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis. Rev Port Cardiol 2021; 40:631-638. [PMID: 34503699 DOI: 10.1016/j.repce.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/26/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM). METHODS The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019. RESULTS In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%). CONCLUSION Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.
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Affiliation(s)
- Stasa Krasic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia
| | - Sergej Prijic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Ninic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia
| | - Dejan Nesic
- School of Medicine, University of Belgrade, Belgrade, Serbia; Institute of Medical Physiology "Rihard Burian", Belgrade, Serbia
| | - Bojko Bjelakovic
- Clinic of Pediatrics - Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - Gordana Petrovic
- Immunology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia
| | - Ivana Cerovic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia
| | - Vladislav Vukomanovic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia.
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Fung RCM, Hon KL, Leung AKC. Acute Myocarditis in Children: An Overview of Treatment and Recent Patents. ACTA ACUST UNITED AC 2021; 14:106-116. [PMID: 32013855 DOI: 10.2174/1872213x14666200204103714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis. METHODS Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine. RESULTS Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking. CONCLUSION This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.
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Affiliation(s)
- Ronald C M Fung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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Comparison and Analysis on the Existing Single-Herbal Strategies against Viral Myocarditis. Genet Res (Camb) 2021; 2021:9952620. [PMID: 34456633 PMCID: PMC8371739 DOI: 10.1155/2021/9952620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/31/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose Herbal medicine is one of crucial symbols of Chinese national medicine. Investigation on molecular responses of different herbal strategies against viral myocarditis is immeasurably conducive to targeting drug development in the current international absence of miracle treatment. Methods Literature retrieval platforms were applied in the collection of existing empirical evidences for viral myocarditis-related single-herbal strategies. SwissTargetPrediction, Metascape, and Discovery Studio coordinating with multidatabases investigated underlying target genes, interactive proteins, and docking molecules in turn. Results Six single-herbal medicines consisting of Huangqi (Hedysarum Multijugum Maxim), Yuganzi (Phyllanthi Fructus), Kushen (Sophorae Flavescentis Radix), Jianghuang (Curcumaelongae Rhizoma), Chaihu (Radix Bupleuri), and Jixueteng (Spatholobus Suberectus Dunn) meet the requirement. There were 11 overlapped and 73 unique natural components detected in these herbs. SLC6A2, SLC6A4, NOS2, PPARA, PPARG, ACHE, CYP2C19, CYP51A1, and CHRM2 were equally targeted by six herbs and identified as viral myocarditis-associated symbols. MCODE algorithm exposed the hub role of SRC and EGFR in strategies without Jianghuang. Subsequently, we learned intermolecular interactions of herbal components and their targeting heart-tissue-specific CHRM2, FABP3, TNNC1, TNNI3, TNNT2, and SCN5A and cardiac-myocytes-specific IL6, MMP1, and PLAT coupled with viral myocarditis. Ten interactive characteristics such as π-alkyl and van der Waals were modeled in which ARG111, LYS253, ILE114, and VAL11 on cardiac troponin (TNNC1-TNNI3-TNNT2) and ARG208, ASN106, and ALA258 on MMP1 fulfilled potential communicating anchor with ellagic acid, 5α, 9α-dihydroxymatrine, and leachianone g via hydrogen bond and hydrophobic interaction, respectively. Conclusions The comprehensive outcomes uncover differences and linkages between six herbs against viral myocarditis through component and target analysis, fostering development of drugs.
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Sheikh FH, Craig PE, Ahmed S, Torguson R, Kolm P, Weintraub WS, Molina EJ, Najjar SS, Mohammed SF. Characteristics and Outcomes of Patients with Inflammatory Cardiomyopathies Receiving Mechanical Circulatory Support: An STS-INTERMACS Registry Analysis. J Card Fail 2021; 28:71-82. [PMID: 34474157 DOI: 10.1016/j.cardfail.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/03/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Durable mechanical circulatory support (MCS) therapy improves survival in patients with advanced heart failure. Knowledge regarding the outcomes experienced by patients with inflammatory cardiomyopathy (CM) who receive durable MCS therapy is limited. METHODS AND RESULTS We compared patients with inflammatory CM with patients with idiopathic dilated CM enrolled in the STS-INTERMACS registry. Among 19,012 patients, 329 (1.7%) had inflammatory CM and 5978 had idiopathic dilated CM (31.4%). The patients with inflammatory CM were younger, more likely to be White, and women. These patients experienced more preoperative arrhythmias and higher use of temporary MCS. Patients with inflammatory CM had a higher rate of early adverse events (<3 months after device implant), including bleeding, arrhythmias, non-device-related infections, neurologic dysfunction, and respiratory failure. The rate of late adverse events (≥3 months) was similar in the 2 groups. Patients with inflammatory CM had a similar 1-year (80% vs 84%) and 2-year (72% vs 76%, P = .15) survival. Myocardial recovery resulting in device explant was more common among patients with inflammatory CM (5.5% vs 2.3%, P < .001). CONCLUSIONS Patients with inflammatory CM who received durable MCS appear to have a similar survival compared with patients with idiopathic dilated CM despite a higher early adverse event burden. Our findings support the use of durable MCS in an inflammatory CM population.
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Affiliation(s)
- Farooq H Sheikh
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC.
| | - Paige E Craig
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Sara Ahmed
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | | | - Paul Kolm
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - William S Weintraub
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Ezequiel J Molina
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Samer S Najjar
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
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Ammirati E, Veronese G, Bottiroli M, Wang DW, Cipriani M, Garascia A, Pedrotti P, Adler ED, Frigerio M. Update on acute myocarditis. Trends Cardiovasc Med 2021; 31:370-379. [PMID: 32497572 PMCID: PMC7263216 DOI: 10.1016/j.tcm.2020.05.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/09/2020] [Accepted: 05/26/2020] [Indexed: 12/14/2022]
Abstract
Acute myocarditis (AM), a recent-onset inflammation of the heart, has heterogeneous clinical presentations, varying from minor symptoms to high-risk cardiac conditions with severe heart failure, refractory arrhythmias, and cardiogenic shock. AM is moving from being a definitive diagnosis based on histological evidence of inflammatory infiltrates on cardiac tissue to a working diagnosis supported by high sensitivity troponin increase in association with specific cardiac magnetic resonance imaging (CMRI) findings. Though experts still diverge between those advocating for histological definition versus those supporting a mainly clinical definition of myocarditis, in the real-world practice the diagnosis of AM has undoubtedly shifted from being mainly biopsy-based to solely CMRI-based in most of clinical scenarios. It is thus important to clearly define selected settings where EMB is a must, as information derived from histology is essential for an optimal management. As in other medical conditions, a risk-based approach should be promoted in order to identify the most severe AM cases requiring appropriate bundles of care, including early recognition, transfer to tertiary centers, aggressive circulatory supports with inotropes and mechanical devices, histologic confirmation and eventual immunosuppressive therapy. Despite improvements in recognition and treatment of AM, including a broader use of promising mechanical circulatory supports, severe forms of AM are still burdened by dismal outcomes. This review is focused on recent clinical studies and registries that shed new insights on AM. Attention will be paid to contemporary outcomes and predictors of prognosis, the emerging entity of immune checkpoint inhibitors-associated myocarditis, updated CMRI diagnostic criteria, new data on the use of temporary mechanical circulatory supports in fulminant myocarditis. The role of viruses as etiologic agents will be reviewed and a brief update on pediatric AM is also provided. Finally, we summarize a risk-based approach to AM, based on available evidence and clinical experience.
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Affiliation(s)
- Enrico Ammirati
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy.
| | - Giacomo Veronese
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Maurizio Bottiroli
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Manlio Cipriani
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Andrea Garascia
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Patrizia Pedrotti
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, United States
| | - Maria Frigerio
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
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Abstract
PURPOSE OF REVIEW We describe the pathophysiology of cardiogenic shock (CS), from the main pathways to the inflammatory mechanisms and the proteomic features. RECENT FINDINGS Although the classical pathophysiological pathways underlying CS, namely reduced organ perfusion due to inadequate cardiac output and peripheral vasoconstriction, have been well-established for a long time, the role of macro-and micro-hemodynamics in the magnitude of the disease and its prognosis has been investigated extensively only over the last few years. Moreover, to complete the complex picture of CS pathophysiology, the study of cytokine cascade, inflammation, and proteomic analysis has been addressed recently. SUMMARY Understanding the pathophysiology of CS is important to treat it optimally.
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Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis. Rev Port Cardiol 2021. [PMID: 34127343 DOI: 10.1016/j.repc.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM). METHODS The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019. RESULTS In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%). CONCLUSION Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.
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Frustaci A, Alfarano M, Verardo R, Agrati C, Casetti R, Miraldi F, Galea N, Letizia C, Chimenti C. Myocarditis-associated necrotizing coronary vasculitis: incidence, cause, and outcome. Eur Heart J 2021; 42:1609-1617. [PMID: 33355356 PMCID: PMC8088814 DOI: 10.1093/eurheartj/ehaa973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/25/2020] [Accepted: 11/26/2020] [Indexed: 01/05/2023] Open
Abstract
AIMS Necrotizing coronary vasculitis (NCV) is a rare entity usually associated to myocarditis which incidence, cause, and response to therapy is unreported. METHODS AND RESULTS Among 1916 patients with biopsy-proven myocarditis, 30 had NCV. Endomyocardial samples were retrospectively investigated with immunohistochemistry for toll-like receptor 4 (TLR4) and real-time polymerase chain reaction (PCR) for viral genomes. Serum samples were processed for anti-heart autoantibodies (Abs), IL-1β, IL-6, IL-8, tumour necrosis factor (TNF)-α. Identification of an immunologic pathway (including virus-negativity, TLR4-, and Ab-positivity) was followed by immunosuppression. Myocarditis-NCV cohort was followed for 6 months with 2D-echo and/or cardiac magnetic resonance and compared with 60 Myocarditis patients and 30 controls. Increase in left ventricular ejection fraction ≥10% was classified as response to therapy. Control endomyocardial biopsy followed the end of treatment. Twenty-six Myocarditis-NCV patients presented with heart failure; four with electrical instability. Cause of Myocarditis-NCV included infectious agents (10%) and immune-mediated causes (chest trauma 3%; drug hypersensitivity 7%; hypereosinophilic syndrome 3%; primary autoimmune diseases 33%, idiopathic 44%). Abs were positive in immune-mediated Myocarditis-NCV and virus-negative Myocarditis; Myocarditis-NCV patients with Ab+ presented autoreactivity in vessel walls. Toll-like receptor 4 was overexpressed in immune-mediated forms and poorly detectable in viral. Interleukin-1β was significantly higher in Myocarditis-NCV than Myocarditis, the former presenting 24% in-hospital mortality compared with 1.5% of Myocarditis cohort. Immunosuppression induced improvement of cardiac function in 88% of Myocarditis-NCV and 86% of virus-negative Myocarditis patients. CONCLUSION Necrotizing coronary vasculitis is histologically detectable in 1.5% of Myocarditis. Necrotizing coronary vasculitis includes viral and immune-mediated causes. Intra-hospital mortality is 24%. The immunologic pathway is associated with beneficial response to immunosuppression.
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Affiliation(s)
- Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy.,Cellular and Molecular Cardiology Lab, IRCCS "Lazzaro Spallanzani", Via Portuense, 292, 00149 Rome, Italy
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS "Lazzaro Spallanzani", Via Portuense, 292, 00149 Rome, Italy
| | - Chiara Agrati
- Cellular Immunology Laboratory, IRCCS "Lazzaro Spallanzani", Via Portuense, 292, 00149 Rome, Italy
| | - Rita Casetti
- Cellular Immunology Laboratory, IRCCS "Lazzaro Spallanzani", Via Portuense, 292, 00149 Rome, Italy
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Nicola Galea
- Department of Experimental Medicine, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Claudio Letizia
- Department of Translation Medicine and Precision, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy.,Cellular and Molecular Cardiology Lab, IRCCS "Lazzaro Spallanzani", Via Portuense, 292, 00149 Rome, Italy
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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Xu G, Chen F, Zhao W, Zheng Y, Zhuang W, Yu F. Establishment and assessment of a nomogram model for predicting the risk of fulminant myocarditis: A STROBE compliant cross-sectional study. Medicine (Baltimore) 2021; 100:e25317. [PMID: 33907091 PMCID: PMC8084052 DOI: 10.1097/md.0000000000025317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 11/27/2022] Open
Abstract
ABSTRACT We aimed to identify potential clinical predictors associated with the risk of fulminant myocarditis, and further to establish and assess a nomogram model based on significant attributes for clinical practicability.This is a retrospective, cross-sectional study, involving 28 patients with fulminant myocarditis and 35 age-, and sex-matched patients with non-fulminant myocarditis. Effect-size estimates are expressed as odds ratio (OR) and 95% confidence interval (CI).Fifteen factors were primarily identified to be associated with the significant risk of fulminant myocarditis after adjusting for confounders. Due to strong correlation, 6 factors were retained, including mean arterial pressure (OR, 95% CI, P: .82, .72-.94, .005), creatinine (2.15, 1.13-4.10, 0.020), blood urea nitrogen (1.45, 1.04-2.02, 0.028), aspartate aminotransferase (2.62, 1.16-5.91, 0.021), troponin I (1.43, 1.07-1.90, 0.015), and ventricular wall motion abnormality (25.81, 2.52-264.69, 0.006). The contribution of the 6 significant factors to predicting fulminant myocarditis risk was significant from multi-angle analyses, and regressing these factors in a nomogram model exhibited good predictive accuracy, as reflected by both C-index (>90%, P < .001).We have identified 6 clinical factors in significant association with fulminant myocarditis, and their prediction capability was more obvious in a nomogram model. Further investigations with larger sample sizes and longer follow-up intervals are warranted.
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Affiliation(s)
- Guifen Xu
- Department of Cardiology, The First Affiliated Hospital, Fujian Medical University
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University
| | - Feizhen Chen
- Department of Ultrasound, The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Wenxiang Zhao
- Department of Cardiology, The First Affiliated Hospital, Fujian Medical University
| | - Yong Zheng
- Department of Cardiology, The First Affiliated Hospital, Fujian Medical University
| | - Wei Zhuang
- Department of Cardiology, The First Affiliated Hospital, Fujian Medical University
| | - Fuling Yu
- Department of Cardiology, The First Affiliated Hospital, Fujian Medical University
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Zuo H, Li H, Li R, Ma F, Jiang J, Li C, Xia L, Wang H, Wang DW. Myocardial strain features by 2D-STE during the course of fulminant myocarditis: Correlation with characteristics by CMR and clinical implications. Medicine (Baltimore) 2021; 100:e25050. [PMID: 33847613 PMCID: PMC8052038 DOI: 10.1097/md.0000000000025050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 02/15/2021] [Indexed: 01/04/2023] Open
Abstract
Myocardial strain analysis by 2D speckle tracking echocardiography could determine the left ventricular function. Our purpose is to investigate the global longitudinal strain (GLS) changes during the course of fulminant myocarditis (FM) and evaluate their correlation with cardiac magnetic resonance (CMR).Patients with clinical diagnosis of FM from June 30, 2017 to June 30, 2019 were screened prospectively. 18 survived patients (mean age 34 ± 18 years) who had two scans of transthoracic echocardiography and underwent CMR were included.All patients had severely impaired left ventricular ejection fraction and GLS value at admission that improved significantly before discharge. The patients in the healed stage revealed elevated global native T1 and T2 relaxation time and extracellular volume fraction as well, which were 1408.3 ± 88.3ms, 46.56 ± 5.23ms, and 0.35 ± 0.09, respectively. GLS from the second transthoracic echocardiography in the healed stage correlated significantly with global native T1 relaxation time (r =-0.574, P = .013) and with extracellular volume fraction (r = -0.582, P = .011), but not global native T2 relaxation time (r = -0.31, P = .211) and not with late gadolinium enhancement mass (r = 0.084, P = .743). In comparison, GLS at admission were not correlated with CMR parameters of fibrosis and oedema in the healed stage.GLS by 2D-STE may emerge as a new tool to monitor inflammatory myocardial injuries during the course of FM. FM in the acute healed stage has the presence of both chronic fibrosis and oedema which are correlated with GLS, but GLS at admission can't predict the early recovery of myocardial inflammation.
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Affiliation(s)
- Houjuan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Haojie Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Fei Ma
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Jiangang Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Chenze Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, Hubei Province
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Extracorporeal Membrane Oxygenation for Fulminant Myocarditis: Increase of Cardiac Enzyme and SOFA Score Is Associated with High Mortality. J Clin Med 2021; 10:jcm10071526. [PMID: 33917387 PMCID: PMC8038703 DOI: 10.3390/jcm10071526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to evaluate the outcomes of patients with fulminant myocarditis and investigate the factors associated with mortality. This is a retrospective single-center cohort study that included adult and pediatric patients with fulminant myocarditis treated at Samsung Medical Center between September 2004 and December 2019. The primary outcome was in-hospital mortality. Among 100 patients, 71 underwent veno-arterial extracorporeal membrane oxygenation (ECMO) (ECMO group). Comorbidities were not significantly different between the ECMO and non-ECMO groups. Cardiac enzymes, creatinine, and median sequential organ failure assessment (SOFA) score at intensive care unit admission were significantly different between the groups. Twenty patients (28.7%) in the ECMO group and two (6.9%) in the non-ECMO group died in-hospital (p = 0.02). The significant risk factors of in-hospital mortality were creatine kinase MB fraction (CK-MB) and SOFA score (p = 0.009 and p = 0.001, respectively) in the ECMO group. In the receiver-operating characteristic curve analysis, the cutoffs of SOFA score and CK-MB were 12 and 94.74 ng/mL, respectively. The patients with both variables above the cutoffs showed significantly worse outcomes (p < 0.001). ECMO can be an effective treatment option for fulminant myocarditis. SOFA score and CK-MB are significant risk factors for in-hospital mortality.
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Characterization and long-term outcomes of patients with myocarditis: a retrospective observational study. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:60-67. [PMID: 33868419 PMCID: PMC8039934 DOI: 10.5114/aic.2021.104770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction There is limited data on the long-term follow-up of patients with myocarditis. Aim To investigate the long-term follow-up of patients with myocarditis. Material and methods We performed a retrospective observational analysis on the clinical long-term outcomes of patients with myocarditis over a 10-year period. The primary outcome was mortality. We identified risk factors for mortality and adverse clinical outcomes. We also compared the characteristics and outcomes of patients presenting with fulminant myocarditis to those presenting with non-fulminant myocarditis. Results Between May 2004 and December 2014, 203 patients with myocarditis or perimyocarditis were admitted to our center. Most patients were male (87.7%) with a median age at presentation of 33 years (interquartile range: 25.4–38.9). The median follow-up period was 56.9 months (interquartile range 25.3–87.3 months), during which the overall mortality was 4.4% (9 patients). Fifteen patients presented with fulminant myocarditis. After multivariable analysis, older age (HR = 1.11, 95% CI: 1.05–1.16, p < 0.001) and a poorer New York Heart Association (NYHA) function class (HR = 4.6, 95% CI: 1.18–18, p = 0.028) were found to be independently associated with a higher risk of mortality, whereas higher albumin levels at presentation (HR = 0.2, 95% CI: 0.07–0.56, p = 0.002) were associated with decreased mortality. The group presenting with fulminant myocarditis had a more severe course of disease and a higher in-hospital mortality (13.3% vs. 0%, p = 0.005). Conclusions The overall prognosis of patients with myocarditis is good – in terms of both survival and recovery without residual left ventricular dysfunction.
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Liu L, Yang X, Gu Y, Jiang T, Xu J, Xu M. Predictive Value of the Age, Creatinine, and Ejection Fraction (ACEF) Score in Patients With Acute Fulminant Myocarditis. Front Physiol 2021; 12:596548. [PMID: 33716762 PMCID: PMC7943611 DOI: 10.3389/fphys.2021.596548] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Patients with acute fulminant myocarditis often have more adverse cardiovascular events and higher mortality. The purpose of this study was to evaluate the usefulness of age, creatinine, and left ventricular ejection fraction (ACEF score), in determining the risk that acute fulminant myocarditis will lead to serious cardiovascular events, death, and cardiac dysfunction. Methods We retrospectively reviewed the demographics, laboratory tests, medications, echocardiographic examinations, in-hospital clinical outcomes, major adverse cardiovascular events (MACE), and survival rate at 1 year in the medical records of 220 consecutive subjects suffering from acute fulminant myocarditis from January 2013 to June 2019. Results Two hundred twenty patients were divided into a survivor group and a non-survivor group. This study found that patients in the non-survivor group were older, had higher heart rates, and had more serious injuries to multiple organ functions. A high ACEF score at admission was independently associated with an unfavorable prognosis, and it was a predictor of in-hospital mortality. The current analysis extends the predictive performance of the ACEF scores at 30 days by evaluating echocardiographic data as applied to survivors of fulminant myocarditis and cumulative rates of MACE at 1 year. The results indicated that patients with high ACEF scores had poor recovery of cardiac function, and higher rates of MACE, all-cause death, and heart failure at 1 year than the low-ACEF group. Conclusion The ACEF score was identified as an effective predictor of poor in-hospital outcomes, worse cardiac recovery after 30 days, and higher rates of MACE, all-cause death, and heart failure at 1 year in patients who had acute fulminant myocarditis. These data suggest that its predictive accuracy means the ACEF score could be used to assess the prognosis of patients with acute fulminant myocarditis.
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Affiliation(s)
- Lin Liu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xinyu Yang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiyu Gu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tingbo Jiang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jialiang Xu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Mingzhu Xu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Abstract
PURPOSE OF REVIEW The clinical syndrome of coronavirus disease 2019 (COVID-19) has become a global pandemic leading to significant morbidity and mortality. Cardiac dysfunction is commonly seen in these patients, often presenting as clinical heart failure. Accordingly, we aim to provide a comprehensive review on COVID-19 myocarditis and its long-term heart failure sequelae. RECENT FINDINGS Several suspected cases of COVID-19 myocarditis have been reported. It is often not clear if the acute myocardial dysfunction is caused by myocarditis or secondary to generalized inflammatory state of cytokine release or microvascular thrombotic angiopathy. Ischemia may also need to be ruled out. Regardless, myocardial dysfunction in these patients is associated with poor overall prognosis. Laboratory testing, echocardiography, cardiac magnetic resonance imaging, and even endomyocardial biopsy may be needed for timely diagnosis. Several treatment strategies have been described, including both supportive and targeted therapies. SUMMARY COVID-19 can cause a spectrum of ventricular dysfunction ranging from mild disease to fulminant myocarditis with hemodynamic instability. Future research is needed to understand the true prevalence of COVID-19 myocarditis, as well as to better define various diagnostic protocols and treatment strategies.
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Affiliation(s)
- Jing Liu
- Section of Cardiology, Department of Medicine, Baylor College of Medicine
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center
| | - Umair Khalid
- Section of Cardiology, Medical Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Valera IC, Wacker AL, Hwang HS, Holmes C, Laitano O, Landstrom AP, Parvatiyar MS. Essential roles of the dystrophin-glycoprotein complex in different cardiac pathologies. Adv Med Sci 2021; 66:52-71. [PMID: 33387942 DOI: 10.1016/j.advms.2020.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 12/20/2022]
Abstract
The dystrophin-glycoprotein complex (DGC), situated at the sarcolemma dynamically remodels during cardiac disease. This review examines DGC remodeling as a common denominator in diseases affecting heart function and health. Dystrophin and the DGC serve as broad cytoskeletal integrators that are critical for maintaining stability of muscle membranes. The presence of pathogenic variants in genes encoding proteins of the DGC can cause absence of the protein and/or alterations in other complex members leading to muscular dystrophies. Targeted studies have allowed the individual functions of affected proteins to be defined. The DGC has demonstrated its dynamic function, remodeling under a number of conditions that stress the heart. Beyond genetic causes, pathogenic processes also impinge on the DGC, causing alterations in the abundance of dystrophin and associated proteins during cardiac insult such as ischemia-reperfusion injury, mechanical unloading, and myocarditis. When considering new therapeutic strategies, it is important to assess DGC remodeling as a common factor in various heart diseases. The DGC connects the internal F-actin-based cytoskeleton to laminin-211 of the extracellular space, playing an important role in the transmission of mechanical force to the extracellular matrix. The essential functions of dystrophin and the DGC have been long recognized. DGC based therapeutic approaches have been primarily focused on muscular dystrophies, however it may be a beneficial target in a number of disorders that affect the heart. This review provides an account of what we now know, and discusses how this knowledge can benefit persistent health conditions in the clinic.
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Affiliation(s)
- Isela C Valera
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Amanda L Wacker
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Hyun Seok Hwang
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Christina Holmes
- Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, Tallahassee, FL, USA
| | - Orlando Laitano
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Andrew P Landstrom
- Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Department of Cell Biology, Duke University School of Medicine, Durham, NC, USA
| | - Michelle S Parvatiyar
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA.
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78
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Wilcox JE, Fang JC, Margulies KB, Mann DL. Heart Failure With Recovered Left Ventricular Ejection Fraction: JACC Scientific Expert Panel. J Am Coll Cardiol 2021; 76:719-734. [PMID: 32762907 DOI: 10.1016/j.jacc.2020.05.075] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 12/25/2022]
Abstract
Reverse left ventricular (LV) remodeling and recovery of LV function are associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction. A growing body of evidence suggests that even among patients who experience a complete normalization of LV ejection fraction, a significant proportion will develop recurrent LV dysfunction accompanied by recurrent heart failure events. This has led to intense interest in understanding how to manage patients with heart failure with recovered ejection fraction (HFrecEF). Because of the lack of a standard definition for HFrecEF, and the paucity of clinical data with respect to the natural history of HFrecEF patients, there are no current guidelines on how these patients should be followed up and managed. Accordingly, this JACC Scientific Expert Panel reviews the biology of reverse LV remodeling and the clinical course of patients with HFrecEF, as well as provides guidelines for defining, diagnosing, and managing patients with HFrecEF.
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Affiliation(s)
- Jane E Wilcox
- Division of Cardiovascular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Kenneth B Margulies
- Translational Research Center, Department of Medicine, University of Pennsylvania Pearlman School of Medicine, Philadelphia, Pennsylvania
| | - Douglas L Mann
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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79
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Golpour A, Patriki D, Hanson PJ, McManus B, Heidecker B. Epidemiological Impact of Myocarditis. J Clin Med 2021; 10:603. [PMID: 33562759 PMCID: PMC7915005 DOI: 10.3390/jcm10040603] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/24/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Myocarditis is an inflammatory disease of the heart muscle with a wide range of potential etiological factors and consequently varying clinical patterns across the world. In this review, we address the epidemiology of myocarditis. Myocarditis was considered a rare disease until intensified research efforts in recent decades revealed its true epidemiological importance. While it remains a challenge to determine the true prevalence of myocarditis, studies are underway to obtain better approximations of the proportions of this disease. Nowadays, the prevalence of myocarditis has been reported from 10.2 to 105.6 per 100,000 worldwide, and its annual occurrence is estimated at about 1.8 million cases. This wide range of reported cases reflects the uncertainty surrounding the true prevalence and a potential underdiagnosis of this disease. Since myocarditis continues to be a significant public health issue, particularly in young adults in whom myocarditis is among the most common causes of sudden cardiac death, improved diagnostic and therapeutic procedures are necessary. This manuscript aims to summarize the current knowledge on the epidemiology of myocarditis, new diagnostic approaches and the current epidemiological impact of the COVID-19 pandemic.
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Affiliation(s)
- Ainoosh Golpour
- Campus Benjamin Franklin, Charite Universitätsmedizin Berlin, 12203 Berlin, Germany;
| | - Dimitri Patriki
- Department of Medicine, Cantonal Hospital of Baden, 15005 Baden, Switzerland;
| | - Paul J. Hanson
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC V5K0A1, Canada; (P.J.H.); (B.M.)
| | - Bruce McManus
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC V5K0A1, Canada; (P.J.H.); (B.M.)
| | - Bettina Heidecker
- Campus Benjamin Franklin, Charite Universitätsmedizin Berlin, 12203 Berlin, Germany;
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80
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Li H, Zhu H, Yang Z, Tang D, Huang L, Xia L. Application of Multiparametric Quantitative Cardiac Magnetic Resonance for Detection and Monitoring of Myocardial Injury in Patients with Fulminant Myocarditis. Acad Radiol 2021; 28:e35-e43. [PMID: 32199722 DOI: 10.1016/j.acra.2020.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES To investigate whether multiparametric cardiac magnetic resonance (CMR) could detect and monitor inflammatory myocardial alterations in fulminant myocarditis. MATERIALS AND METHODS Nineteen patients (35 ± 14 years, 37% male) with clinical diagnosis of fulminant myocarditis underwent CMR examinations at 3.0T in the acute phase and at 3-months follow up. The control group consisted of 19 healthy volunteers. The CMR protocol included cine, black blood T2-weighted imaging, T1 mapping, T2 mapping and late gadolinium enhancement (LGE). Cardiac parameters, such as edema ratio, LGE mass, native T1, T2 and extracellular volume were measured. RESULTS The left ventricular mass index (67 ± 15 versus 55 ± 12 g/m2, p < 0.05) and interventricular septum thickness (10.4 ± 1.5 versus 8.3 ± 1.8 mm, p < 0.001) in acute stage was significantly higher compared to controls, and normalized at the chronic stage. All quantitative inflammation metrics, including edema ratio, LGE mass, native T1, T2 and extracellular volume were significantly (all p < 0.001) decreased in the follow-up scan, but still higher compared to controls. Compared to the controls, all global strain indices including circumferential, longitudinal and radial strain values were significantly impaired in acute stage (all p < 0.001). Native T1 and T2 values led to excellent diagnostic accuracy for discriminating fulminant myocarditis from healed myocarditis, with AUC of 0.947 and 0.931. CONCLUSION Multiparametric CMR could detect and monitor inflammation myocardial injuries in patients with fulminant myocarditis. Native T1 and T2 values achieved excellent diagnostic performance in distinguishing acute from healed myocarditis.
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81
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Georgiopoulos G, Figliozzi S, Sanguineti F, Aquaro GD, di Bella G, Stamatelopoulos K, Chiribiri A, Garot J, Masci PG, Ismail TF. Prognostic Impact of Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance in Myocarditis: A Systematic Review and Meta-Analysis. Circ Cardiovasc Imaging 2021; 14:e011492. [PMID: 33441003 DOI: 10.1161/circimaging.120.011492] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with acute myocarditis (AM) are at increased risk of adverse cardiac events after the index episode. Late gadolinium enhancement (LGE) detected by cardiovascular magnetic resonance in patients with AM plays an important diagnostic role, but its prognostic significance remains unresolved. This systematic review and meta-analysis sought to assess the prognostic implications of cardiovascular magnetic resonance-derived LGE in patients with AM. METHODS Data search was conducted from inception through February 28, 2020, using the following Medical Subject Heading terms: Myocarditis, CMR, Magnetic Resonance Imaging, Magnetic Resonance. From 2422 articles retrieved, we selected 11 studies reporting baseline cardiovascular magnetic resonance assessment and long-term clinical follow-up in patients with AM. Hazard ratios and CIs for a combined clinical end point were recorded for LGE presence, extent (>2 segments or >10% of left ventricular [LV] mass or >17g) and location (anteroseptal versus non-anteroseptal). A combined end point comprised all-cause mortality, cardiac mortality, and major adverse cardiovascular events. Hartung and Knapp correction improved robustness of the results. Prespecified sensitivity analyses explored potential sources of heterogeneity. The meta-analysis was conducted according to the Meta-analysis of Observational Studies in Epidemiology guidelines. RESULTS LGE presence (pooled hazard ratios, 3.28 [95% CIs, 1.69-6.39], P<0.001 [95% CIs, 1.33-8.11] after Hartung and Knapp correction) and anteroseptal LGE (pooled-hazard ratios, 2.58 [95% CIs, 1.87-3.55], P<0.001 [95% CIs, 1.64-4.06] after Hartung and Knapp correction) were associated with an increased risk of the combined end point. Extensive LGE was associated with worse outcomes (pooled-hazard ratios, 1.96 [95% CIs, 1.08-3.56], P=0.027), but this association was not confirmed after Hartung and Knapp correction (95% CIs, 0.843-4.57). CONCLUSIONS LGE presence and anteroseptal location at baseline cardiovascular magnetic resonance are important independent prognostic markers that herald an increased risk of adverse cardiac outcomes in patients with AM. Registration: https://www.crd.york.ac.uk/PROSPERO/ Unique identifier: CRD42019146619.
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Affiliation(s)
- Georgios Georgiopoulos
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom (G.G., S.F., A.C., P.G.M., T.F.I.).,Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece (G.G., K.S.)
| | - Stefano Figliozzi
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom (G.G., S.F., A.C., P.G.M., T.F.I.)
| | - Francesca Sanguineti
- Cardiovascular MR Lab, ICPS, Hôpital Privé Jacques Cartier-Ramsay Santé, Massy, France (F.S., J.G.)
| | | | - Gianluca di Bella
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Italy (G.d.B.)
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece (G.G., K.S.)
| | - Amedeo Chiribiri
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom (G.G., S.F., A.C., P.G.M., T.F.I.)
| | - Jerome Garot
- Cardiovascular MR Lab, ICPS, Hôpital Privé Jacques Cartier-Ramsay Santé, Massy, France (F.S., J.G.)
| | - Pier Giorgio Masci
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom (G.G., S.F., A.C., P.G.M., T.F.I.)
| | - Tevfik F Ismail
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom (G.G., S.F., A.C., P.G.M., T.F.I.)
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Peretto G, Sala S, Rizzo S, Palmisano A, Esposito A, De Cobelli F, Campochiaro C, De Luca G, Foppoli L, Dagna L, Thiene G, Basso C, Della Bella P. Ventricular Arrhythmias in Myocarditis: Characterization and Relationships With Myocardial Inflammation. J Am Coll Cardiol 2020; 75:1046-1057. [PMID: 32138965 DOI: 10.1016/j.jacc.2020.01.036] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Ventricular arrhythmias (VAs) have never been systematically investigated in patients with myocarditis at different stages. OBJECTIVES The purpose of this study was to compare baseline and follow-up characteristics of VAs in patients with active myocarditis (AM) versus previous myocarditis (PM). METHODS A total of 185 consecutive patients (69% males, age 44 ± 15 years, left ventricular ejection fraction 49 ± 14%) with myocarditis and VA at index hospitalization, including ventricular fibrillation, ventricular tachycardia (VT), nonsustained ventricular tachycardia (NSVT), and Lown's grade ≥2 premature ventricular complexes, were enrolled. AM and PM groups were defined based on endomyocardial biopsy and cardiac magnetic resonance findings. A subset of patients (n = 46, 25%) also underwent electroanatomic mapping and VA transcatheter ablation. RESULTS At presentation, AM patients (n = 123, 66%) more commonly had ventricular fibrillation (8 cases vs. 0 cases; p = 0.053), and both irregular (61% vs. 11%; p < 0.001) and polymorphic VA (NSVT and VT: 19% vs. 2%; p = 0.002; premature ventricular complexes: 63% vs. 16%; p < 0.001). Only in PM patients with NSVT or VT, the dominant morphology (right-bundle branch block with superior axis) was 100% predictive of abnormal LV inferoposterior substrate at both cardiac magnetic resonance and electroanatomic mapping. At 27 ± 7 months prospective follow-up, 55 patients (30%) experienced malignant VA (AM vs. PM, p = 0.385). Although a prevalence of polymorphic and irregular VA was confirmed in AM patients with persistent inflammation in follow-up (58%), a predominance of monomorphic and regular VA was found in AM patients after myocarditis healing (42%), as well as in PM patients (all p < 0.001). CONCLUSIONS In myocarditis patients, polymorphic and irregular VA are more common during the active inflammatory phase, whereas monomorphic and regular VA are associated with healed myocarditis.
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Affiliation(s)
- Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy.
| | - Simone Sala
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Stefania Rizzo
- Department of Cardiovascular Pathology, Padua Hospital and University, Padua, Italy
| | - Anna Palmisano
- Department of Cardiovascular Radiology and Cardiac Magnetic Resonance Unit, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Antonio Esposito
- Department of Cardiovascular Radiology and Cardiac Magnetic Resonance Unit, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Francesco De Cobelli
- Department of Cardiovascular Radiology and Cardiac Magnetic Resonance Unit, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Luca Foppoli
- IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Gaetano Thiene
- Department of Cardiovascular Pathology, Padua Hospital and University, Padua, Italy
| | - Cristina Basso
- Department of Cardiovascular Pathology, Padua Hospital and University, Padua, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
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The diagnostic capability of electrocardiography on the cardiogenic shock in the patients with acute myocarditis. BMC Cardiovasc Disord 2020; 20:502. [PMID: 33256622 PMCID: PMC7708141 DOI: 10.1186/s12872-020-01796-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
Background The study was performed to assess the diagnostic capability of ECG on the cardiogenic shock (CS) in acute myocarditis. A new score was derived from the combination of the ECG parameters and the diagnostic value was also evaluated. Methods Total 103 consecutive patients with acute myocarditis admitted in Nanjing Drum Hospital were enrolled in the current study. The cohort was divided into fulminant myocarditis group (FM, n = 20) and non fulminant myocarditis group (NFM, n = 83). The demographic features, results of electrocardiography (ECG) and ultracardiography were compared. Logistic regression analysis was conducted to identify the relevant factors in ECG parameters. We created a new variable called “ECG score” by certain combination of ECG parameters. The diagnostic capability of ECG score for CS was compared with the existing diagnostic indices using regression model and receiver-operating characteristics (ROC) analysis.
Results There were several changes on ECG significantly different between the two groups. Multivariate regression analysis demonstrated PR + QRS interval (P = 0.008), ventricular arrhythmia (P = 0.001) and pathological Q wave (P = 0.003) were the independent relevant factors of CS. The derived variable “ECG score” was identified as a significant relevant factor of CS by multivariate regression model. ROC analysis showed PR + QRS interval, ventricular arrhythmia and pathological Q wave all had equivalent diagnostic capability to left ventricular ejection fraction (LVEF) and shock index (SI). ECG score was equivalent to LVEF but superior to SI in diagnosing CS Conclusions ECG was valuable in diagnosing CS due to acute myocarditis. The ECG score was superior to the traditional diagnostic indices and could be used for an rapid recognition of CS.
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85
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Zhang Q, Zhao R. Risk factors analysis of prognosis of adult acute severe myocarditis. World J Clin Cases 2020; 8:5547-5554. [PMID: 33344545 PMCID: PMC7716313 DOI: 10.12998/wjcc.v8.i22.5547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/31/2020] [Accepted: 09/16/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adult severe myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock with a high hospital mortality rate.
AIM To analyze the risk factors affecting the short-term prognosis of adult acute severe myocarditis (ASM).
METHODS Adult patients with ASM (ASM group, n = 218) and acute nonsevere myocarditis (ANSM group, n = 80) who came to our department from January 2014 to January 2020 were enrolled in this study. Patients with ASM were divided into the ASM survival group (n = 185) and ASM nonsurvival group (n = 33) according to the treatment results during hospitalization. The clinical symptoms, laboratory examinations, treatment methods, complications, and the relationship between the treatment results of the two groups were retrospectively compared and discussed. The risk factors for death in patients with severe myocarditis were analyzed by binary logistic regression. A follow-up to 5.5 years was conducted on patients in the ASM survival group and ANSM group after discharge, and the readmission rate and incidence rate of dilated cardiomyopathy were analyzed.
RESULTS Compared with the ASM survival group, the ASM nonsurvival group had longer QRS complex, higher incidence of cardiogenic shock, higher serum creatinine (SCr, 235μmol/L vs 89 μmol/L, P < 0.05), higher sensitive cardiac troponin I (cTnI, 4.45 μg/L vs 1.66 μg/L, P < 0.05) and brain natriuretic peptide (BNP, 1756 pg/mL vs 401 pg/mL, P < 0.05). The binary logistic regression revealed that there were statistical differences between the two groups in SCr, cTnI, and BNP values (all P < 0.05). After discharging from the hospital, patients in the ASM group and ANSM group had no significant differences in the readmission rate and incidence rate of dilated cardiomyopathy.
CONCLUSION Elevated SCr, cTnI, and BNP are independent predictors for poor prognosis in patients with ASM. The long-term prognosis of patients in the ASM survival group is good.
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Affiliation(s)
- Qian Zhang
- Department of Heart Center, Peking University People's Hospital, Beijing 100044, China
| | - Rui Zhao
- Department of Heart Center, Peking University People's Hospital, Beijing 100044, China
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86
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Yang H, Lu Y, Yang H, Yuan J. Clinical characteristics and treatment effects of astragalus injection in non-pediatric patients with acute fulminant myocarditis. Medicine (Baltimore) 2020; 99:e23062. [PMID: 33235067 PMCID: PMC7710263 DOI: 10.1097/md.0000000000023062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To explore the clinical characteristics of non-pediatric patients with acute fulminant myocarditis (AFM) and evaluate the treatment effects of astragalus injection on this disease.A total of 54 AFM patients were screened out from 586 patients with acute myocarditis, admitted to the department of cardiology between January 2011 to June 2018. The demographic and clinical data, investigations, treatments, and short-term outcomes were collected and retrospectively analyzed.The mean age of the 54 AFM patients was 34 ± 16.5 years old (range: 13-70 years), including 24 (44.5%) men and 30 (55.5%) women, with a high incidence in 2 age groups: 13-19 and 40-49 years old, despite an inverse trend to the increase of age. All these cases were admitted in emergency conditions: 26 (48.1%) cardiogenic shock, 18 (33.4%) malignant arrhythmias, 8 (14.8%) severe heart failure, and 2 (3.7%) acute pericardial tamponade. Apart from first-aid measures, 37 (68.5%) patients received astragalus injection. During hospitalization, 11 (20.4%) patients died, and 4 (36.3%) of them were from astragalus group while 7 (63.7%) of them from without-astragalus group (P=0.03). Furthermore, the levels of cardiac injury biomarkers, renal function and left ventricular ejection fraction of astragalus group were significantly improved compared with those of without-astragalus group at discharge (all P < .05).Middle-aged people were also prone to AFM. And cardiac shock was the most common, while acute pericardial tamponade was a rare presentation in non-pediatric AFM patients. Astragalus was a potential adjuvant medicine for the treatment of AFM.
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87
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Zhang Y, Li X, Wang D, Jiang X, Zhang M, Lv K. Serum exosome microRNA panel as a noninvasive biomarker for molecular diagnosis of fulminant myocarditis. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2020; 20:142-151. [PMID: 33473354 PMCID: PMC7786026 DOI: 10.1016/j.omtm.2020.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/10/2020] [Indexed: 12/02/2022]
Abstract
Exosome-derived microRNAs (miRNAs) are potential diagnostic biomarkers. However, little is known about their effectiveness as diagnostic biomarkers of fulminant myocarditis (FM). This study aimed to explore serum exosomal miRNAs as potential biomarkers for FM diagnosis. Peripheral blood samples were collected from 99 patients with FM, 32 patients with nonfulminant myocarditis (NFM), and 105 healthy controls (HCs). The miRNA expression profiles of serum exosomes were determined using next-generation sequencing, and differentially expressed miRNAs were further analyzed by quantitative reverse transcriptase polymerase chain reaction. A logistic regression model was constructed using a training cohort (n = 120) and then validated using an independent cohort (n = 106). The area under the receiver operating characteristic curve was used to evaluate diagnostic accuracy. In FM patients, hsa-miR-30a, hsa-miR-192, hsa-miR-146a, hsa-miR-155, and hsa-miR-320a were validated as significantly and differentially expressed candidates that could serve as potential markers for diagnosing FM. In addition, the miRNA panel (hsa-miR-155 and hsa-miR-320a) from the multivariate logistic regression model demonstrated high accuracy in the diagnosis of FM and was able to distinguish FM from HCs and NFM. Moreover, the diagnostic value of the miRNA panel was greater than that of CRP and cTn alone or together. The miRNA panel provided the excellent diagnostic capability for FM.
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Affiliation(s)
- Yingying Zhang
- Key Laboratory of Non-coding RNA Transformation Research of Anhui Higher Education Institutes, Wuhu, PR China.,Department of Laboratory Medicine, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, PR China
| | - Xueqin Li
- Key Laboratory of Non-coding RNA Transformation Research of Anhui Higher Education Institutes, Wuhu, PR China.,Department of Central Laboratory, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu 241001, PR China
| | - Deguo Wang
- Department of Gerontology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, PR China
| | - Xiaogan Jiang
- Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, PR China
| | - Mengying Zhang
- Key Laboratory of Non-coding RNA Transformation Research of Anhui Higher Education Institutes, Wuhu, PR China.,Department of Central Laboratory, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu 241001, PR China
| | - Kun Lv
- Key Laboratory of Non-coding RNA Transformation Research of Anhui Higher Education Institutes, Wuhu, PR China.,Department of Central Laboratory, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu 241001, PR China
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88
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Turgeon PY, Massot M, Beaupré F, Belzile D, Beaudoin J, Bernier M, Bourgault C, Germain V, Laliberté C, Morin J, Gervais P, Trahan S, Charbonneau É, Dagenais F, Sénéchal M. Effect of Acute Immunosuppression on Left Ventricular Recovery and Mortality in Fulminant Viral Myocarditis: A Case Series and Review of Literature. CJC Open 2020; 3:292-302. [PMID: 33778446 PMCID: PMC7985012 DOI: 10.1016/j.cjco.2020.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
Background Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies. Methods We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM. Results We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery. Conclusions Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.
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Affiliation(s)
- Pierre Yves Turgeon
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Montse Massot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Frédéric Beaupré
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - David Belzile
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Jonathan Beaudoin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Christine Bourgault
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Valérie Germain
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Claudine Laliberté
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Joëlle Morin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Philippe Gervais
- Department of Infectious Disease, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Sylvain Trahan
- Department of Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Éric Charbonneau
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
| | - Mario Sénéchal
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
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89
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Ammirati E, Frigerio M, Adler ED, Basso C, Birnie DH, Brambatti M, Friedrich MG, Klingel K, Lehtonen J, Moslehi JJ, Pedrotti P, Rimoldi OE, Schultheiss HP, Tschöpe C, Cooper LT, Camici PG. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document. Circ Heart Fail 2020; 13:e007405. [PMID: 33176455 PMCID: PMC7673642 DOI: 10.1161/circheartfailure.120.007405] [Citation(s) in RCA: 335] [Impact Index Per Article: 83.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | - Maria Frigerio
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | - Eric D. Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla (E.D.A., M.B.)
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy (C.B.)
| | - David H. Birnie
- University of Ottawa Heart Institute, Ontario, Canada (D.H.B.)
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla (E.D.A., M.B.)
- IONIS Pharmaceuticals, Carlsbad, CA (M.B.)
| | - Matthias G. Friedrich
- Department of Medicine and Diagnostic Radiology, McGill University, Montreal, Quebec, Canada (M.G.F.)
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Germany (K.K.)
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital, Finland (J.L.)
| | - Javid J. Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.J.M.)
| | - Patrizia Pedrotti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | | | | | - Carsten Tschöpe
- Institute of Health Center for Regenerative Therapies (BCRT), Charité, University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany (C.T.)
- Department of Cardiology, Charité–University Medicine Berlin, Campus Virchow Klinikum, Germany (C.T.)
| | - Leslie T. Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Paolo G. Camici
- Vita Salute University and San Raffaele Hospital, Milano, Italy (P.G.C.)
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90
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Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis. Int J Cardiol 2020; 324:131-138. [PMID: 33122017 DOI: 10.1016/j.ijcard.2020.10.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 01/19/2023]
Abstract
Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.
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91
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Abstract
Myocarditis in the pediatric population can be a challenging diagnosis to make and often requires utilization of multiple diagnostic modalities. The cause is often due to a viral infection with activation of the innate and acquired immune response with either recovery or disease progression. Laboratory testing often includes inflammatory markers, cardiac troponin levels, and natriuretic peptides. Noninvasive testing should include electrocardiogram, echocardiogram, and possibly an MRI. Treatment of myocarditis remains controversial with most providers using immune modulators with intravenous immunoglobulin and corticosteroids.
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92
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Kim J, Cho MJ. Acute Myocarditis in Children: a 10-year Nationwide Study (2007-2016) based on the Health Insurance Review and Assessment Service Database in Korea. Korean Circ J 2020; 50:1013-1022. [PMID: 32812406 PMCID: PMC7596206 DOI: 10.4070/kcj.2020.0108] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/17/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We performed a nationwide study to assess the incidence, treatment patterns, and outcomes of acute myocarditis in Korean children. METHODS The nationwide incidence, treatment patterns, and outcomes of acute myocarditis in Korean children were assessed using data between 2007 and 2016 from the Health Insurance Review and Assessment database. RESULTS We investigated 1,627 children during the study period. The overall incidence of acute myocarditis was 1.4 per 100,000 children in 2007 and 2.1 per 100,000 children in 2016, which indicates a significant increase in the trend over time. A bimodal age distribution was observed with a larger peak in infancy and a smaller peak in the mid-teenage years. No sex difference was observed in the incidence rate of acute myocarditis in children aged ≤5 years (373 boys vs. 366 girls); however, the incidence rate of acute myocarditis in adolescents aged ≥13 years showed significant male preponderance (482 boys vs. 152 girls). Acute fulminant myocarditis occurred in 371 children (22.8%) who needed extracorporeal membrane oxygenation and/or mechanical ventilator support. Of the 371 children with acute fulminant myocarditis, 258 (69.5%) survived. The survival rate of children with acute fulminant myocarditis remained nearly identical over the 10-year study period. CONCLUSIONS This was the first nationwide epidemiological study to investigate acute myocarditis in Korean children. In our view, this study would help clinicians in decision-making and planning for optimal management of acute myocarditis in children.
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Affiliation(s)
- Jinmi Kim
- Biomedical Research Institute of Pusan National University Hospital, Busan, Korea
| | - Min Jung Cho
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea.
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93
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Robinson J, Hartling L, Vandermeer B, Sebastianski M, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2020; 8:CD004370. [PMID: 32835416 PMCID: PMC8210245 DOI: 10.1002/14651858.cd004370.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND This is an update of a previous review. Case reports and case series have described dramatic responses to intravenous immunoglobulin (IVIG) in people with presumed viral myocarditis, and its administration has become commonplace. OBJECTIVES The primary objective of this review was to compare event-free (death, requirement for a cardiac transplant, or placement of a left ventricular assist device) or overall (death) survival of adults and children with presumed viral myocarditis treated with IVIG versus those who did not receive IVIG. A secondary objective was to determine if a group of patients with presumed viral myocarditis could be identified (on the basis of age, duration of symptoms, acuity of onset of symptoms, cardiac function at presentation, virological results, or the presence or absence of histological evidence of acute myocarditis on cardiac biopsy in patients in whom a biopsy was performed) who would be the most likely to benefit from IVIG. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, DARE, CINAHL, Web of Science Core Collection, and LILACS in July 2019, and two trial registries in November 2019. We contacted authors of trials and checked reference lists of relevant papers. We applied no language restrictions. SELECTION CRITERIA We included studies if (1) participants had a clinical diagnosis of acute myocarditis with a left ventricular ejection fraction (LVEF) ≤ 0.45, left ventricular end-diastolic diameter (LVEDD) > 2 standard deviations (SDs) above the norm, or a left ventricular shortening fraction (LVSF) > 2 SDs below the mean, with duration of cardiac symptoms < 6 months; (2) participants had no evidence of non-infectious or bacterial cardiac disease; and (3) participants were randomly assigned to receive at least 1 g/kg of IVIG versus no IVIG or placebo. We excluded studies if (1) participants had received immunosuppression before outcome assessment; or (2) onset of myocarditis was reported to have occurred < 6 months postpartum. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results and extracted data. We assessed risk of bias with the Cochrane 'Risk of bias' tool. We conducted meta-analysis for two outcomes (overall survival and improvement in LVEF) with two adult trials. Other meta-analyses were not possible because only three relevant trials were included, and researchers analysed markedly different populations and used different outcome measures. MAIN RESULTS In this update we added two trials to the two previously included trials. A quasi-randomised trial was previously included due to a paucity of evidence from randomised trials; however, with the addition of two new randomised trials, it was removed from this update. For two adult trials, the overall risk of bias was unclear with very low-certainty evidence for all outcomes. The first trial studied 62 adults with recent-onset dilated cardiomyopathy randomly assigned to receive IVIG or an equivalent volume of 0.1% albumin in a blinded fashion. The effect on event-free survival between groups was uncertain (risk ratio (RR) of any event 1.76, 95% confidence interval (CI) 0.48 to 6.40). The second trial studied 41 adults with acute myocarditis randomised to either high-dose IVIG (1 to 2 g/kg over two days) or no treatment. The IVIG group reported greater survival time after 60 days (no raw data, P < 0.01), but the evidence is uncertain. We pooled the reported number of deaths in both trials, with no evidence of a difference between groups (RR 0.91, 95% CI 0.23 to 3.62, I2 = 31%, very low-certainty evidence). The evidence on the effect of IVIG treatment on LVEF (pooled mean difference (MD) -0.01, 95% CI -0.06 to 0.05) after 12 months and an unknown time frame is uncertain. The results for functional capacity, assessed by peak oxygen consumption at 12 months, were uncertain (MD -0.80, 95% CI -4.57 to 2.97). The results for infusion-related side effects were also uncertain due to a very large CI (RR 20.29, 95% CI 1.25 to 329.93). Lastly, there was uncertain evidence addressing failure to attain complete recovery (RR 0.46, 95% CI 0.19 to 1.14). Evidence for improvement in LVEDD, left ventricular shortening fraction, and hospitalisation status in adults was not reported. In the single included paediatric trial, the overall risk of bias was low with very low-certainty evidence for all outcomes. The trial included 86 children in Egypt presenting with acute myocarditis. Children were randomly assigned to 1 g/kg IVIG daily for two consecutive days or placebo followed by echocardiography one and six months post randomisation for recording of LVEDD and LVSF. The evidence for overall survival after six months was uncertain (risk of death RR 0.48, 95% CI 0.20 to 1.15). The evidence was also uncertain for improvement in LVEDD and LVSF after six months (LVEDD MD -4.00, 95% CI -9.52 to 1.52; LVSF no raw data). Evidence for improvement in LVEF, functional capacity, side effects, complete recovery, and hospitalisation status in children was not reported. AUTHORS' CONCLUSIONS: Evidence from two trials of very low certainty and with unclear risk of bias provides contradictory evidence on the use of IVIG in the treatment of adults with presumed viral myocarditis. One trial reported that use of IVIG results in longer survival time after 60 days, whilst the other trial found that IVIG does not provide an appreciable benefit. The evidence of a difference in event-free or overall survival, LVEDD, or LVSF is of very low certainty in a single paediatric trial with a low risk of bias. Until higher-quality studies with low risk of bias and larger sample sizes have demonstrated benefit in a particular group of patients, the evidence for treatment with IVIG for presumed viral myocarditis is uncertain. Further studies of the pathophysiology of myocarditis would lead to improved diagnostic criteria, which would facilitate future research.
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Affiliation(s)
- Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Lisa Hartling
- Department of Pediatrics and the Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Ben Vandermeer
- Department of Pediatrics and the Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Meghan Sebastianski
- Pediatrics (AB SPOR Knowledge Translation Unit), University of Alberta, Edmonton, Canada
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Extracorporeal Cardiopulmonary Resuscitation for Management of Out-of-Hospital Cardiac Arrest in a Patient with Fulminant Myocarditis. Case Rep Crit Care 2020; 2020:8881042. [PMID: 32832163 PMCID: PMC7428952 DOI: 10.1155/2020/8881042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/07/2020] [Accepted: 07/14/2020] [Indexed: 11/17/2022] Open
Abstract
A 68-year-old male with a witnessed out-of-hospital cardiac arrest while jogging who was managed with extracorporeal cardiopulmonary resuscitation (ECPR) is presented. The patient was found to be in refractory ventricular fibrillation by emergency medical service personnel and underwent advanced cardiac life support (ACLS) protocol with placement of an automated chest compression device. He was emergently transported to the cardiac catheterization laboratory. Due to refractory ventricular fibrillation, he was placed on venoarterial extracorporeal membranous oxygenation (VA-ECMO). Coronary angiography at that time showed nonobstructive coronary artery disease. Management with VA-ECMO and other supportive measures were continued for 5 days, after which a cardiac magnetic resonance imaging was performed with findings consistent with acute myocarditis. His condition substantially improved, and he was discharged from the hospital with good neurologic and functional status. Fulminant myocarditis is often fatal, but aggressive supportive measures with novel ECPR protocols may result in recovery, as it happened in this case.
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95
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D'Arcy JL, Manen O, Davenport ED, Syburra T, Rienks R, Guettler N, Bron D, Gray G, Nicol ED. Heart muscle disease management in aircrew. Heart 2020; 105:s50-s56. [PMID: 30425086 PMCID: PMC6256300 DOI: 10.1136/heartjnl-2018-313058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/17/2018] [Accepted: 09/30/2018] [Indexed: 01/01/2023] Open
Abstract
This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with suspected or confirmed heart muscle disease (both pilots and non-pilot aviation professionals). ECG abnormalities on aircrew periodic medical examination or presentation of a family member with a confirmed cardiomyopathy are the most common reason for investigation of heart muscle disease in aircrew. Holter monitoring and imaging, including cardiac MRI is recommended to confirm or exclude the presence of heart muscle disease and, if confirmed, management should be led by a subspecialist. Confirmed heart muscle disease often requires restriction toflying duties due to concerns regarding arrhythmia. Pericarditis and myocarditis usually require temporary restriction and return to flying duties is usually dependent on a lack of recurrent symptoms and acceptable imaging and electrophysiological investigations.
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Affiliation(s)
- Joanna L D'Arcy
- Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire, Oxfordshire, UK
| | - Olivier Manen
- Aviation Medicine Department, AeMC, Percy Military Hospital, Clamart, Île-de-France, France
| | - Eddie D Davenport
- Aeromedical Consult Service, United States Air Force School of Aerospace Medicine, Wright-Patterson AFB, Ohio, USA
| | - Thomas Syburra
- Cardiac Surgery Department, Luzerner Kantonsspital, Luzern, Switzerland
| | - Rienk Rienks
- Department of Cardiology, University Medical Center Utrecht and Central Military Hospital, Utrecht, The Netherlands
| | - Norbert Guettler
- German Air Force Center for Aerospace Medicine, Fuerstenfeldbruck, Germany
| | - Dennis Bron
- Aeromedical Centre, Swiss Air Force, Duebendorf, Switzerland
| | - Gary Gray
- Canadian Forces Environmental Medical Establishment, Toronto, Ontario, Canada
| | - Edward D Nicol
- Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire, Oxfordshire, UK
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96
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Jurcova I, Rocek J, Bracamonte-Baran W, Zelizko M, Netuka I, Maluskova J, Kautzner J, Cihakova D, Melenovsky V, Maly J. Complete recovery of fulminant cytotoxic CD8 T-cell-mediated myocarditis after ECMELLA unloading and immunosuppression. ESC Heart Fail 2020; 7:1976-1981. [PMID: 32485066 PMCID: PMC7373888 DOI: 10.1002/ehf2.12697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/20/2020] [Accepted: 03/13/2020] [Indexed: 01/23/2023] Open
Abstract
A 19‐year‐old woman with no previous cardiac history was admitted to the hospital with third‐degree atrioventricular block and left ventricular dysfunction. Her condition quickly deteriorated to severe biventricular failure and cardiogenic shock requiring mechanical circulatory support. An endomyocardial biopsy revealed lymphocytic myocarditis with no PCR‐detectable viral genomes, with CD8 T‐cell predominance and pro‐inflammatory macrophage expansion shown by myocardial flow cytometry. The therapy consisted of immunosuppression (high‐dose methylprednisolone) and temporary mechanical circulatory support with enhanced ability to achieve left ventricular unloading by combination of extracorporeal membrane oxygenation with Impella (ECMELLA). After 2 weeks of support, complete and sustained recovery from myocarditis was observed.
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Affiliation(s)
- Ivana Jurcova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Jan Rocek
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | | | - Michael Zelizko
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Ivan Netuka
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Jana Maluskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Daniela Cihakova
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
| | - Jiri Maly
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Prague 4, Czech Republic
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97
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Ammirati E, Veronese G, Brambatti M, Merlo M, Cipriani M, Potena L, Sormani P, Aoki T, Sugimura K, Sawamura A, Okumura T, Pinney S, Hong K, Shah P, Braun Ö, Van de Heyning CM, Montero S, Petrella D, Huang F, Schmidt M, Raineri C, Lala A, Varrenti M, Foà A, Leone O, Gentile P, Artico J, Agostini V, Patel R, Garascia A, Van Craenenbroeck EM, Hirose K, Isotani A, Murohara T, Arita Y, Sionis A, Fabris E, Hashem S, Garcia-Hernando V, Oliva F, Greenberg B, Shimokawa H, Sinagra G, Adler ED, Frigerio M, Camici PG. Fulminant Versus Acute Nonfulminant Myocarditis in Patients With Left Ventricular Systolic Dysfunction. J Am Coll Cardiol 2020; 74:299-311. [PMID: 31319912 DOI: 10.1016/j.jacc.2019.04.063] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/23/2019] [Accepted: 04/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular systolic dysfunction requiring inotropes and/or mechanical circulatory support. A single-center study found that a patient with FM had better outcomes than those with acute nonfulminant myocarditis (NFM) presenting with left ventricular systolic dysfunction, but otherwise hemodynamically stable. This was recently challenged, so disagreement still exists. OBJECTIVES This study sought to provide additional evidence on the outcome of FM and to ascertain whether patient stratification based on the main histologic subtypes can provide additional prognostic information. METHODS A total of 220 patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) all presenting with left ventricular systolic dysfunction were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The main endpoint was the occurrence of cardiac death or heart transplantation within 60 days from admission and at long-term follow-up. RESULTS Patients with FM (n = 165) had significantly higher rates of cardiac death and heart transplantation compared with those with NFM (n = 55), both at 60 days (28.0% vs. 1.8%, p = 0.0001) and at 7-year follow-up (47.7% vs. 10.4%, p < 0.0001). Using Cox multivariate analysis, the histologic subtype emerged as a further variable affecting the outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis. In a subanalysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with in NFM both at 60 days (19.5% vs. 0%, p = 0.005) and at 7-year follow up (41.4% vs. 3.1%, p = 0.0004). CONCLUSIONS This international registry confirms that patients with FM have higher rates of cardiac death and heart transplantation both in the short- and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy.
| | - Giacomo Veronese
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Marco Merlo
- Cardiothoracic Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy
| | | | | | - Paola Sormani
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy
| | - Tatsuo Aoki
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | | | | | - Sean Pinney
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kimberly Hong
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Öscar Braun
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | | | - Santiago Montero
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, CIBER-CV, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13, France
| | | | - Florent Huang
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13, France
| | - Matthieu Schmidt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13, France
| | - Claudia Raineri
- Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Anuradha Lala
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marisa Varrenti
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Alberto Foà
- Academic Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Ornella Leone
- Academic Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Piero Gentile
- Cardiothoracic Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy
| | - Jessica Artico
- Cardiothoracic Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy
| | | | - Rajiv Patel
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | | | | | | | - Yoh Arita
- Japan Community Healthcare Organization, Osaka Hospital, Osaka, Japan
| | - Alessandro Sionis
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, CIBER-CV, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Enrico Fabris
- Cardiothoracic Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy
| | - Sherin Hashem
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Victor Garcia-Hernando
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, CIBER-CV, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy
| | - Barry Greenberg
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
| | | | - Gianfranco Sinagra
- Cardiothoracic Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milano, Italy
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98
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Rroku A, Kottwitz J, Heidecker B. Update on myocarditis - what we know so far and where we may be heading. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620910109. [PMID: 32319308 DOI: 10.1177/2048872620910109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Andi Rroku
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | | | - Bettina Heidecker
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
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99
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Younis A, Matetzky S, Mulla W, Masalha E, Afel Y, Chernomordik F, Fardman A, Goitein O, Ben-Zekry S, Peled Y, Grupper A, Beigel R. Epidemiology Characteristics and Outcome of Patients With Clinically Diagnosed Acute Myocarditis. Am J Med 2020; 133:492-499. [PMID: 31712098 DOI: 10.1016/j.amjmed.2019.10.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/30/2019] [Accepted: 10/24/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are controversial data regarding the outcome and management of patients hospitalized with clinically diagnosed acute myocarditis. METHODS We retrospectively evaluated data of 322 consecutive patients admitted to the Sheba Medical Center with clinically suspected acute myocarditis from January 2005 to December 2017. Patients were subdivided into 2 groups based on their left ventricular ejection fraction (LVEF) at presentation: 1) patients with an LVEF <50% (n = 60) and 2) patients with an LVEF ≥50% (n = 260). We aimed to evaluate the clinical characteristics, management, and in-hospital outcome as well as short-term and 1-year outcome of patients admitted with acute myocarditis. RESULTS The mean age of the study population was 37 ± 14 years, most of them (84%) males. Although chest pain was the main complaint in 89% of the patients at presentation, only 35% had typical pericardial pain. Patients with a LVEF <50% were more likely to demonstrate ST depression or T wave inversion on their electrocardiogram (ECG) at presentation (33% vs 18%, P = 0.007), and have higher levels of admission and peak troponin compared to those with LVEF ≥50%,(12.7 μ/L ± 15 µ/L vs 5.5 μ/L ± 9.2 μ/L, P = 0.001 for admission troponin, 18.8 μ/L ± 19.9 μ/L vs 8.4 μ/L ± 11.6 μ/L, P <0.001, for peak troponin). Univariate analysis showed that patients with an LVEF <50% were more likely to suffer from adverse cardiovascular events, defined as a composite of the following: 1) acute decompensated congestive heart failure; 2) ventricular arrhythmias; and 3) in-hospital mortality, compared to those with an LVEF ≥50% (15 [25%] vs10 [4%], P <0.001). Consistently, multivariable analysis showed that patients with an LVEF <50% had a 4-fold increased risk of adverse cardiovascular events compared to those patients with an LVEF ≥50% (heart rate [HR] = 4.30; 95% confidence interval [CI] 1.59-11.49; P <0.001). CONCLUSIONS Patients with clinical acute myocarditis seem to have an overall good prognosis. Although patients with an LVEF <50% are at a higher risk of in-hospital adverse events compared to those with an LVEF ≥50%, this propensity is not reflected during 1-year of follow-up.
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Affiliation(s)
- Anan Younis
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Shlomi Matetzky
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Wesam Mulla
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyas Masalha
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Afel
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fernando Chernomordik
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alex Fardman
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Goitein
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sagit Ben-Zekry
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishay Grupper
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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100
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Prognostic factors for heart recovery in adult patients with acute fulminant myocarditis and cardiogenic shock supported with extracorporeal membrane oxygenation. J Crit Care 2020; 57:214-219. [PMID: 32220770 DOI: 10.1016/j.jcrc.2020.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/21/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an effective support method for acute fulminant myocarditis (AFM) with cardiogenic shock. However, deciding whether to bridge to a left ventricular assist device (LVAD) or to maintain ECMO support until heart recovery is still controversial. MATERIAL AND METHODS This was a retrospective observational study from a single center. Eighty-eight adults with AFM and ECMO support between 2006 and 2018 were included. The primary endpoint was heart recovery without heart transplantation or long-term LVAD support. RESULTS The heart recovery group contained 43 patients, of whom 41 were discharged after being weaned off ECMO and the other two after LVAD. Five patients with heart transplants and one with long-term LVAD support were discharged, accounting for an overall survival of 55.7%. Multivariate logistic regression revealed that peak CK-MB level, severe intraventricular conduction disturbance (asystole) and malignant arrhythmia (VT or VF) were prognostic factors for nonrecovery (P = .027 and 0.017, respectively), while early intravenous immunoglobulin (IVIG) use before ECMO was highly likely to have a protective effect with a trend toward statistical significance (P = .079). A risk score was developed: 4 points for VT/VF/asystole, 1 point for every 100 μg/L increase in the peak CK-MB level, up to a maximum of 5 points, and -3 points for early IVIG use. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.818. CONCLUSION High CK-MB levels and VT/VF/asystole in patients with AFM are associated with poor heart recovery. Early IVIG use shows a potentially protective effect.
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