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Abstract
Myocarditis is generally a mild and self-limited consequence of systemic infection of cardiotropic viruses. However, patients can develop a temporary or permanent impairment of cardiac function including acute cardiomyopathy with hemodynamic compromise or severe arrhythmias. In this setting, specific causes of inflammation are associated with variable risks of death and transplantation. Recent translational studies suggest that treatments tailored to specific causes of myocarditis may impact clinical outcomes when added to guideline-directed medical care. This review summarizes recent advances in translational research that influence the utility of endomyocardial biopsy for the management of inflammatory cardiomyopathies. Emerging therapies for myocarditis based on these mechanistic hypotheses are entering clinical trials and may add to the benefits of established heart failure treatment.
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Affiliation(s)
- Carsten Tschöpe
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Guillermo Torre-Amione
- Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX (G.T.-A.).,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Nuevo León, Mexico (G.T.-A.)
| | - Sophie Van Linthout
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
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102
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Li H, Zhu H, Yang Z, Tang D, Huang L, Xia L. Tissue Characterization by Mapping and Strain Cardiac MRI to Evaluate Myocardial Inflammation in Fulminant Myocarditis. J Magn Reson Imaging 2020; 52:930-938. [PMID: 32080960 DOI: 10.1002/jmri.27094] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The clinical value of novel mapping techniques and strain measures to assess myocardial inflammation in fulminant myocarditis (FM) has not been fully explored. PURPOSE To evaluate the ability of mapping and strain cardiac MRI to assess myocardial inflammation in patients with FM, and to which degree the strain metrics correlate with myocardial edema. STUDY TYPE Prospective. POPULATION Twenty-nine patients (37 ± 16 years, 48% male) with FM and 29 patients with nonfulminant acute myocarditis (NFAM) (29 ± 14 years, 69% male). FIELD STRENGTH/SEQUENCE 3.0T; Cine imaging, black blood T2 -weighted imaging, T1 mapping, T2 mapping, and late gadolinium enhancement. ASSESSMENT Native T1 , extracellular volume (ECV), and T2 were measured. Myocardial strain was evaluated by feature tracking. STATISTICAL TESTS Student's t- or Mann-Whitney U-test. Spearman correlation analysis. RESULTS The myocardial edema rate (2.6 ± 0.7 vs. 1.6 ± 0.2, P < 0.001) and late gadolinium enhancement (LGE) mass (16.5 [11.7, 41.7] vs. 6.9 [2.2, 15.8] g, P < 0.001) were significantly increased in FM patients when compared to the NFAM group. LGE in the FM group was predominantly located in the septal wall, and 38% of the patients showed a diffuse LGE pattern. Native T1 , ECV, and T2 values in the FM group were significantly more elevated than those with NFAM, while global peak radial, circumferential, and longitudinal strain values were significantly reduced (all P < 0.001). Circumferential strain showed the strongest correlations with ECV (r = 0.72, P < 0.001). DATA CONCLUSION Patients with FM showed significant differences in LGE patterns, increased edema, and decreased strain measurements compared to those with NFAM. Circumferential strain showed significant associations with quantitative cardiac MRI parameters of myocardial inflammation. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:930-938.
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Affiliation(s)
- Haojie Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dazhong Tang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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103
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Ali-Ahmed F, Dalgaard F, Al-Khatib SM. Sudden cardiac death in patients with myocarditis: Evaluation, risk stratification, and management. Am Heart J 2020; 220:29-40. [PMID: 31765933 DOI: 10.1016/j.ahj.2019.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 08/09/2019] [Indexed: 12/27/2022]
Abstract
Myocarditis is a major cause of sudden cardiac death (SCD) and dilated cardiomyopathy (DCM) in young adults. Cardiac magnetic resonance is the established tool for the diagnosis of myocarditis, and late gadolinium enhancement detected on cardiac magnetic resonance imaging is the strongest independent predictor of SCD, all-cause mortality, and cardiac mortality. Several other factors have been associated with SCD or cardiac transplantation including New York Heart Association functional class III/IV, reduced left ventricular ejection fraction <35%, and right ventricular ejection fraction ≤45%. A fragmented QRS and a prolonged QTc interval on an electrocardiogram are predictors of VAs. The postulated mechanism of VA in acute myocarditis is ion channel dysfunction and inflammation that alter intracellular signaling, producing interstitial edema and fibrosis and thereby causing conduction abnormalities. VAs in chronic myocarditis are generally due to scar-mediated reentry. Treatment of myocarditis is tailored toward supportive care and symptomatic relief. The subset of patients who develop DCM should be treated with heart failure medications according to professional guideline recommendations. Indications for an implantable cardioverter-defibrillator are similar to those for nonischemic cardiomyopathy; however, an implantable cardioverter-defibrillator should be held in the acute phase of myocarditis to allow left ventricular ejection fraction recovery, and a wearable cardioverter-defibrillator may be beneficial for some patients. Antiarrhythmic medications are reserved for patients with symptomatic nonsustained or sustained VAs. Radiofrequency ablation appears to be an effective treatment option for VAs; however, more data on its safety and effectiveness are needed. This review addresses risk factors of SCD and VAs in patients with myocarditis with special emphasis on treatment and prevention of these outcomes.
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104
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Olejniczak M, Schwartz M, Webber E, Shaffer A, Perry TE. Viral Myocarditis-Incidence, Diagnosis and Management. J Cardiothorac Vasc Anesth 2020; 34:1591-1601. [PMID: 32127272 DOI: 10.1053/j.jvca.2019.12.052] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 12/25/2022]
Abstract
Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.
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Affiliation(s)
- Megan Olejniczak
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Matthew Schwartz
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Elizabeth Webber
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Andrew Shaffer
- University of Minnesota, Department of Cardiothoracic Surgery, Minneapolis, MN
| | - Tjorvi E Perry
- University of Minnesota, Department of Anesthesia, Minneapolis, MN.
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105
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Kociol RD, Cooper LT, Fang JC, Moslehi JJ, Pang PS, Sabe MA, Shah RV, Sims DB, Thiene G, Vardeny O. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e69-e92. [PMID: 31902242 DOI: 10.1161/cir.0000000000000745] [Citation(s) in RCA: 316] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure. Historically, FM was almost exclusively diagnosed at autopsy. By definition, all patients with FM will need some form of inotropic or mechanical circulatory support to maintain end-organ perfusion until transplantation or recovery. Specific subtypes of FM may respond to immunomodulatory therapy in addition to guideline-directed medical care. Despite the increasing availability of circulatory support, orthotopic heart transplantation, and disease-specific treatments, patients with FM experience significant morbidity and mortality as a result of a delay in diagnosis and initiation of circulatory support and lack of appropriately trained specialists to manage the condition. This scientific statement outlines the resources necessary to manage the spectrum of FM, including extracorporeal life support, percutaneous and durable ventricular assist devices, transplantation capabilities, and specialists in advanced heart failure, cardiothoracic surgery, cardiac pathology, immunology, and infectious disease. Education of frontline providers who are most likely to encounter FM first is essential to increase timely access to appropriately resourced facilities, to prevent multiorgan system failure, and to tailor disease-specific therapy as early as possible in the disease process.
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106
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Zarak-Crnkovic M, Kania G, Jaźwa-Kusior A, Czepiel M, Wijnen WJ, Czyż J, Müller-Edenborn B, Vdovenko D, Lindner D, Gil-Cruz C, Bachmann M, Westermann D, Ludewig B, Distler O, Lüscher TF, Klingel K, Eriksson U, Błyszczuk P. Heart non-specific effector CD4 + T cells protect from postinflammatory fibrosis and cardiac dysfunction in experimental autoimmune myocarditis. Basic Res Cardiol 2019; 115:6. [PMID: 31863205 PMCID: PMC6925074 DOI: 10.1007/s00395-019-0766-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 12/04/2019] [Indexed: 12/14/2022]
Abstract
Heart-specific CD4+ T cells have been implicated in development and progression of myocarditis in mice and in humans. Here, using mouse models of experimental autoimmune myocarditis (EAM) we investigated the role of heart non-specific CD4+ T cells in the progression of the disease. Heart non-specific CD4+ T cells were obtained from DO11.10 mice expressing transgenic T cell receptor recognizing chicken ovalbumin. We found that heart infiltrating CD4+ T cells expressed exclusively effector (Teff) phenotype in the EAM model and in hearts of patients with lymphocytic myocarditis. Adoptive transfer experiments showed that while heart-specific Teff infiltrated the heart shortly after injection, heart non-specific Teff effectively accumulated during myocarditis and became the major heart-infiltrating CD4+ T cell subset at later stage. Restimulation of co-cultured heart-specific and heart non-specific CD4+ T cells with alpha-myosin heavy chain antigen showed mainly Th1/Th17 response for heart-specific Teff and up-regulation of a distinct set of extracellular signalling molecules in heart non-specific Teff. Adoptive transfer of heart non-specific Teff in mice with myocarditis did not affect inflammation severity at the peak of disease, but protected the heart from adverse post-inflammatory fibrotic remodelling and cardiac dysfunction at later stages of disease. Furthermore, mouse and human Teff stimulated in vitro with common gamma cytokines suppressed expression of profibrotic genes, reduced amount of α-smooth muscle actin filaments and decreased contraction of cardiac fibroblasts. In this study, we provided a proof-of-concept that heart non-specific Teff cells could effectively contribute to myocarditis and protect the heart from the dilated cardiomyopathy outcome.
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Affiliation(s)
- Martina Zarak-Crnkovic
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Gabriela Kania
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Marcin Czepiel
- Department of Clinical Immunology, Jagiellonian University Medical College, University Children's Hospital, Wielicka 265, 30-663, Cracow, Poland
| | - Winandus J Wijnen
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Jarosław Czyż
- Department of Cell Biology, Jagiellonian University, Cracow, Poland
| | - Björn Müller-Edenborn
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
- Department of Medicine, GZO-Zurich Regional Health Center, Wetzikon, Switzerland
| | - Daria Vdovenko
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Diana Lindner
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Cristina Gil-Cruz
- Institute of Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marta Bachmann
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Dirk Westermann
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Burkhard Ludewig
- Institute of Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Oliver Distler
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University of Tubingen, Tubingen, Germany
| | - Urs Eriksson
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
- Department of Medicine, GZO-Zurich Regional Health Center, Wetzikon, Switzerland
| | - Przemysław Błyszczuk
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, Zurich, Switzerland.
- Department of Clinical Immunology, Jagiellonian University Medical College, University Children's Hospital, Wielicka 265, 30-663, Cracow, Poland.
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107
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Zuo H, Li R, Ma F, Jiang J, Miao K, Li H, Nagel E, Tadic M, Wang H, Wang DW. Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline. Front Med 2019; 14:284-292. [PMID: 31858367 DOI: 10.1007/s11684-019-0713-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/23/2019] [Indexed: 12/23/2022]
Abstract
The features of myocardial strains from speckle-tracking echocardiography (STE) have not been well defined in fulminant myocarditis (FM) patients. In this study, changes in the left ventricular ejection fraction (LVEF) and global and layer-specific myocardial strains over time were monitored. We aimed to determine the echocardiographic patterns of FM and ascertain their significance in FM treatment. Twenty patients who were clinically diagnosed with FM and received mechanical life support were prospectively enrolled. Conventional echocardiographic measurements were obtained, and serial strain echocardiography was performed from admission to hospital discharge until LVEF recovery (> 50%). Global/regional peak systolic longitudinal strains (GLS/RLS) and layer-specific longitudinal strains were quantified, and their changes with time were monitored in 14 FM patients. All patients had severely impaired cardiac function. Steep improvement in LVEF and GLS were observed within 6 days. Layer-specific strain analysis showed that reduction at admission or recovery at discharge in the endocardium and epicardium strains were equal. In conclusion, FM patients who received mechanical circulatory supports exhibited steep improvement in ventricular function within 6 days. The patchy and diffused distribution pattern of reduced RLS and equally and severely impaired strain in the endocardium and epicardium are valuable features in the diagnosis of FM.
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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, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China
| | - Rui Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China
| | - Fei Ma
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China
| | - Jiangang Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China
| | - Kun Miao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China
| | - Haojie Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Marijana Tadic
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Hong Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan, 430030, China.
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108
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Sharma AN, Stultz JR, Bellamkonda N, Amsterdam EA. Fulminant Myocarditis: Epidemiology, Pathogenesis, Diagnosis, and Management. Am J Cardiol 2019; 124:1954-1960. [PMID: 31679645 DOI: 10.1016/j.amjcard.2019.09.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022]
Abstract
Fulminant myocarditis (FM) is a rare, distinct form of myocarditis that has been difficult to classify. Since 1991, the definition of FM has evolved, and it is currently considered an acute illness with hemodynamic derangement and arrhythmias due to a severe inflammatory process requiring support of cardiac pump function and/or urgent management of serious arrhythmias. Diagnosis is aided through use of biomarkers and cardiac imaging, but endocardial biopsy remains the gold standard. Recent evidence has revealed that patients with FM are significantly more likely to die or require heart transplantation than those with the nonfulminant form, refuting previous studies proposing a paradoxically low mortality in patients with FM. Acute hemodynamic derangement is managed by intensive contemporary pharmacologic and interventional approaches, whereas the role of immunosuppressive therapy has not been clarified. Early recognition and aggressive management are essential for favorable outcomes. In conclusion, FM is an inflammatory process requiring intensive support, and it causes a higher morbidity and mortality than acute nonfulminant myocarditis.
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Affiliation(s)
- Ajay Nair Sharma
- School of Medicine, University of California, Irvine, California
| | | | - Nikhil Bellamkonda
- David Geffen School of Medicine, University of California, Los Angeles, California
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109
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Mavrogeni SI, Markousis-Mavrogenis G, Aggeli C, Tousoulis D, Kitas GD, Kolovou G, Iliodromitis EK, Sfikakis PP. Arrhythmogenic Inflammatory Cardiomyopathy in Autoimmune Rheumatic Diseases: A Challenge for Cardio-Rheumatology. Diagnostics (Basel) 2019; 9:diagnostics9040217. [PMID: 31835542 PMCID: PMC6963646 DOI: 10.3390/diagnostics9040217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
Ventricular arrhythmia (VA) in autoimmune rheumatic diseases (ARD) is an expression of autoimmune inflammatory cardiomyopathy (AIC), caused by structural, electrical, or inflammatory heart disease, and has a serious impact on a patient’s outcome. Myocardial scar of ischemic or nonischemic origin through a re-entry mechanism facilitates the development of VA. Additionally, autoimmune myocardial inflammation, either isolated or as a part of the generalized inflammatory process, also facilitates the development of VA through arrhythmogenic autoantibodies and inflammatory channelopathies. The clinical presentation of AIC varies from oligo-asymptomatic presentation to severe VA and sudden cardiac death (SCD). Both positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) can diagnose AIC early and be useful tools for the assessment of therapies during follow-ups. The AIC treatment should be focused on the following: (1) early initiation of cardiac medication, including ACE-inhibitors, b-blockers, and aldosterone antagonists; (2) early initiation of antirheumatic medication, depending on the underlying disease; and (3) potentially implantable cardioverter–defibrillator (ICD) and/or ablation therapy in patients who are at high risk for SCD.
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Affiliation(s)
- Sophie I. Mavrogeni
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
- Correspondence:
| | | | - Constantina Aggeli
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - Dimitris Tousoulis
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - George D. Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PT, UK;
| | - Genovefa Kolovou
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
| | | | - Petros P. Sfikakis
- First Department of Propeudeutic and Internal medicine, Laikon Hospital, Athens University Medical School, 17674 Athens, Greece;
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110
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Abstract
RATIONALE Fulminant myocarditis (FM) has poor prognosis and the usual treatment is inotropes and symptomatic support. The initiation of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) in the emergency department (ED) is a rare event. PATIENT CONCERNS We report the case of a 45-year-old man with a complaint of 4 days of high fever and dry cough in the emergency department. DIAGNOSIS Transthoracic echocardiogram and the medical history showed presumptive diagnosis was fulminant myocarditis with cardiogenic shock. INTERVENTIONS The patient's condition deteriorated drastically and ECMO was initiated immediately after admission. He experienced electrical storm twice during ECMO support and was successfully treated with the combination with IABP. OUTCOMES ECMO and IABP were continued for 11 and 14 days respectively. The patient was discharged on the 81th day after admission, with all his laboratory tests returned to normal. LESSONS SUBSECTIONS The early initiation of ECMO and IABP in the ED is potentially life-saving for suitable patients with FM. It appears promising but has not yet been routinely implemented in underdeveloped and developing countries.
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111
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Imanaka-Yoshida K. Inflammation in myocardial disease: From myocarditis to dilated cardiomyopathy. Pathol Int 2019; 70:1-11. [PMID: 31691489 DOI: 10.1111/pin.12868] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
Dilated cardiomyopathy (DCM) is a heterogeneous group of myocardial diseases clinically defined by the presence of left ventricular dilatation and contractile dysfunction. Among various causes of DCM, a progression from viral myocarditis to DCM has long been hypothesized. Supporting this possibility, studies by endomyocardial biopsy, the only method to obtain a definite diagnosis of myocarditis at present, have provided evidence of inflammation in the myocardium in DCM patients. A number of experimental studies have elucidated a cell-mediated autoimmune mechanism triggered by viral infection in the progression of myocarditis to DCM. In addition, the important role of inflammation in the pathogenesis of heart failure has been recognized, and many terms including myocarditis, inflammatory cardiomyopathy, and inflammatory DCM have been used for myocardial diseases associated with inflammation. This review discusses the pathophysiology of inflammation in the myocardium, and refers to diagnosis and treatment based on these concepts.
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Affiliation(s)
- Kyoko Imanaka-Yoshida
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Mie, Japan.,Mie University Research Center for Matrix Biology, Mie, Japan
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112
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Schubert S, Opgen-Rhein B, Boehne M, Weigelt A, Wagner R, Müller G, Rentzsch A, Zu Knyphausen E, Fischer M, Papakostas K, Wiegand G, Ruf B, Hannes T, Reineker K, Kiski D, Khalil M, Steinmetz M, Fischer G, Pickardt T, Klingel K, Messroghli DR, Degener F. Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry "MYKKE". Pediatr Transplant 2019; 23:e13548. [PMID: 31297930 DOI: 10.1111/petr.13548] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/16/2019] [Accepted: 06/22/2019] [Indexed: 01/01/2023]
Abstract
Myocarditis represents an important cause for acute heart failure. MYKKE, a prospective multicenter registry of pediatric patients with myocarditis, aims to gain knowledge on courses, diagnostics, and therapy of pediatric myocarditis. The role of mechanical circulatory support (MCS) in children with severe heart failure and myocarditis is unclear. The aim of this study was to determine characteristics and outcome of patients with severe heart failure requiring MCS and/or heart transplantation. The MYKKE cohort between September 2013 and 2016 was analyzed. A total of 195 patients were prospectively enrolled by 17 German hospitals. Twenty-eight patients (14%) received MCS (median 1.5 years), more frequently in the youngest age group (0-2 years) than in the older groups (P < 0.001; 2-12 and 13-18 years). In the MCS group, 50% received a VAD, 36% ECMO, and 14% both, with a survival rate of 79%. The weaning rate was 43% (12/28). Nine (32%) patients were transplanted, one had ongoing support, and six (21%) died. Histology was positive for myocarditis in 63% of the MCS group. Patients within the whole cohort with age <2 years and/or ejection fraction <30% had a significantly worse survival with high risk for MCS, transplantation, and death (P < 0.001). Myocarditis represents a life-threatening disease with an overall mortality of 4.6% in this cohort. The fulminant form more often affected the youngest, leading to significantly higher rate of MCS, transplantation, and mortality. MCS represents an important and life-saving therapeutic option in children with myocarditis with a weaning rate of 43%.
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Affiliation(s)
- Stephan Schubert
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Bernd Opgen-Rhein
- Department for Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Annika Weigelt
- Department for Pediatric Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Robert Wagner
- Department for Pediatric Cardiology, Herzzentrum Leipzig, Leipzig, Germany
| | - Götz Müller
- Department for Pediatric Cardiology, Universitäres Herzzentrum Hamburg, Hamburg, Germany
| | - Axel Rentzsch
- Department for Pediatric Cardiology, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Edzard Zu Knyphausen
- Department for Pediatric Cardiology, Herz- und Diabetes-zentrum NRW, Bad Oeynhausen, Germany
| | - Marcus Fischer
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig Maximilians University of Munich, Munich, Germany
| | | | - Gesa Wiegand
- Department for Pediatric Cardiology, University Hospital Tübingen, Tübingen, Germany
| | - Bettina Ruf
- Department for Pediatric Cardiology, Deutsches Herzzentrum München, München, Germany
| | - Tobias Hannes
- Department for Pediatric Cardiology, University Hospital Köln, Köln, Germany
| | - Katja Reineker
- Department for Pediatric Cardiology, Universitäts-Herzzentrum Freiburg Bad Krozingen, Freiburg, Germany
| | - Daniela Kiski
- Department for Pediatric Cardiology, University Hospital Münster, Münster, Germany
| | - Markus Khalil
- Department for Pediatric Cardiology, University Hospital Gießen, Giessen, Germany
| | - Michael Steinmetz
- Department for Pediatric Cardiology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Gunther Fischer
- Department for Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel R Messroghli
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Department for Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.,Department for Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Degener
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Institute for Cardiovascular Computer-assisted Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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113
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Ammirati E, Cipriani M, Moro C, Raineri C, Pini D, Sormani P, Mantovani R, Varrenti M, Pedrotti P, Conca C, Mafrici A, Grosu A, Briguglia D, Guglielmetto S, Perego GB, Colombo S, Caico SI, Giannattasio C, Maestroni A, Carubelli V, Metra M, Lombardi C, Campodonico J, Agostoni P, Peretto G, Scelsi L, Turco A, Di Tano G, Campana C, Belloni A, Morandi F, Mortara A, Cirò A, Senni M, Gavazzi A, Frigerio M, Oliva F, Camici PG. Clinical Presentation and Outcome in a Contemporary Cohort of Patients With Acute Myocarditis: Multicenter Lombardy Registry. Circulation 2019; 138:1088-1099. [PMID: 29764898 DOI: 10.1161/circulationaha.118.035319] [Citation(s) in RCA: 232] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is controversy about the outcome of patients with acute myocarditis (AM), and data are lacking on how patients admitted with suspected AM are managed. We report characteristics, in-hospital management, and long-term outcome of patients with AM based on a retrospective multicenter registry from 19 Italian hospitals. METHODS A total of 684 patients with suspected AM and recent onset of symptoms (<30 days) were screened between May 2001 and February 2017. Patients >70 years of age and those >50 years of age without coronary angiography were excluded. The final study population comprised 443 patients (median age, 34 years; 19.4% female) with AM diagnosed by either endomyocardial biopsy or increased troponin plus edema and late gadolinium enhancement at cardiac magnetic resonance. RESULTS At presentation, 118 patients (26.6%) had left ventricular ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, whereas 325 (73.4%) had no such complications. Endomyocardial biopsy was performed in 56 of 443 (12.6%), and a baseline cardiac magnetic resonance was performed in 415 of 443 (93.7%). Cardiac mortality plus heart transplantation rates at 1 and 5 years were 3.0% and 4.1%. Cardiac mortality plus heart transplantation rates were 11.3% and 14.7% in patients with complicated presentation and 0% in uncomplicated cases (log-rank P<0.0001). Major AM-related cardiac events after the acute phase (postdischarge death and heart transplantation, sustained ventricular arrhythmias treated with electric shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8% at the 5-year follow-up, with a higher incidence in patients with complicated forms (10.8% versus 0% in uncomplicated AM; log-rank P<0.0001). β-Adrenoceptor blockers were the most frequently used medications both in complicated (61.9%) and in uncomplicated forms (53.8%; P=0.18). After a median time of 196 days, 200 patients had follow-up cardiac magnetic resonance, and 8 of 55 (14.5%) with complications at presentation had left ventricular ejection fraction <50% compared with 1 of 145 (0.7%) of those with uncomplicated presentation. CONCLUSIONS In this contemporary study, overall serious adverse events after AM were lower than previously reported. However, patients with left ventricular ejection fraction <50%, ventricular arrhythmias, or low cardiac output syndrome at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent left ventricular systolic dysfunction.
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Affiliation(s)
| | - Manlio Cipriani
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | | | - Claudia Raineri
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Daniela Pini
- Humanitas Clinical and Research Center, Rozzano, Italy (D.P., R.M.)
| | - Paola Sormani
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | | | - Marisa Varrenti
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Patrizia Pedrotti
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Cristina Conca
- San Carlo Borromeo Hospital, Milan, Italy (C. Conca, A. Mafrici)
| | - Antonio Mafrici
- San Carlo Borromeo Hospital, Milan, Italy (C. Conca, A. Mafrici)
| | - Aurelia Grosu
- Papa Giovanni XXIII Hospital, Bergamo, Italy (A. Grosu, M.S.)
| | | | - Silvia Guglielmetto
- San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy (S.G., G.B.P.)
| | - Giovanni B Perego
- San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy (S.G., G.B.P.)
| | - Stefania Colombo
- Azienda Socio Sanitaria Territoriale Valle Olona, Gallarate Hospital, Italy (S.C., S.I.C.)
| | - Salvatore I Caico
- Azienda Socio Sanitaria Territoriale Valle Olona, Gallarate Hospital, Italy (S.C., S.I.C.)
| | - Cristina Giannattasio
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
- University of Milano-Bicocca, Milan, Italy (C.G.)
| | | | | | - Marco Metra
- Spedali Civili, University of Brescia, Italy (V.C., M.M., C.L.)
| | - Carlo Lombardi
- Spedali Civili, University of Brescia, Italy (V.C., M.M., C.L.)
| | - Jeness Campodonico
- Monzino Center, Istituto di Ricerca e Cura a Carattere Scientifico, Milan, Italy (J.C., P.A.)
| | - Piergiuseppe Agostoni
- Monzino Center, Istituto di Ricerca e Cura a Carattere Scientifico, Milan, Italy (J.C., P.A.)
- Department of Clinical Sciences and Community Health, University of Milan, Italy (P.A.)
| | - Giovanni Peretto
- Vita Salute University and San Raffaele Hospital, Milan, Italy (G.P., P.G.C.)
| | - Laura Scelsi
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Annalisa Turco
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Giuseppe Di Tano
- Azienda Socio Sanitaria Territoriale Cremona, Cremona Hospital, Italy (G.D.T.)
| | | | | | - Fabrizio Morandi
- Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (F.M.)
| | | | | | - Michele Senni
- Papa Giovanni XXIII Hospital, Bergamo, Italy (A. Grosu, M.S.)
| | - Antonello Gavazzi
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation Ospedale Papa Giovanni XXIII, Bergamo, Italy (A. Gavazzi)
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy (G.P., P.G.C.)
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114
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Patriki D, Kottwitz J, Berg J, Landmesser U, Lüscher TF, Heidecker B. Clinical Presentation and Laboratory Findings in Men Versus Women with Myocarditis. J Womens Health (Larchmt) 2019; 29:193-199. [PMID: 31464553 DOI: 10.1089/jwh.2018.7618] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objectives: Understanding sex differences in myocarditis is crucial to improve clinical care. We sought to investigate sex differences focusing on clinical presentation and laboratory parameters. Methods: From 2011 to 2018, 77 patients were diagnosed with myocarditis according to European Society of Cardiology (ESC) criteria with available clinical, laboratory, and cardiac magnetic resonance imaging data. First, we investigated sex differences of clinical and laboratory parameters in the entire cohort of 77 patients. Second, we focused on patients with acute myocarditis (n = 51) defined as recent symptom onset (≤10 days). Results: Myocarditis was present in 63 men (82%) and 14 women (18%). While men most frequently presented with chest pain (78%), a considerable amount of women presented with dyspnea as the only symptom (40%). Within the entire cohort, only creatinine kinase (CK) was higher in men versus women (364 ± 286 vs. 147 ± 148 U/L, p = 0.007), while in patients with acute myocarditis both CK and myoglobin (Mb) were higher in men versus women (CK: 327 ± 223 vs. 112 ± 65 U/L, p = 0.004 and Mb: 111 ± 126 vs. 25 ± 29 μg/L, p = 0.04). No sex differences were found for high-sensitivity troponin T, C-reactive protein, and NT-probrain natriuretic peptide. Conclusions: This is the first study reporting sex differences in clinical presentation and routine laboratory parameters in myocarditis. While clinical presentation appeared to be subtle in women with dyspnea being the only presenting symptom of myocarditis in a considerable part, men typically complained of chest pain. Similarly to observations in myocardial infarction, atypical symptoms and underdiagnosis may be a cause for under-representation of women in cohorts of myocarditis.
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Affiliation(s)
| | | | - Jan Berg
- University Hospital Zurich, Zurich, Switzerland
| | - Ulf Landmesser
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Royal Brompton and Harefield Hospitals and Imperial College, London, United Kingdom
| | - Bettina Heidecker
- University Hospital Zurich, Zurich, Switzerland.,Berlin Institute of Health (BIH), Berlin, Germany
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115
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Early Detection of Localized Immunity in Experimental Autoimmune Myocarditis Using [ 99mTc]Fucoidan SPECT. Mol Imaging Biol 2019; 22:643-652. [PMID: 31432389 DOI: 10.1007/s11307-019-01420-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of the study was to evaluate the ability of technetium-99m-fucoidan ([99mTc]fucoidan), a molecular imaging agent specific for selectins, in the assessment of early localized immunity in a rat model of experimental autoimmune myocarditis (EAM). PROCEDURES EAM was induced in Lewis rats and troponin T; brain natriuretic peptide (BNP) and anti-myosin antibodies were measured in plasma. Separately, [99mTc]fucoidan single-photon emission computed tomography (SPECT)/x-ray computed tomography (CT) was performed in the very early phase of myocarditis at 10, 15, and 21 days after immunization. Then, hearts were collected and used for autoradiography, well counting, histology, and flow cytometry analysis. RESULTS The EAM acute phase is characterized by extensive myocardial necrosis, release of troponin and BNP, and pericardial effusion. [99mTc]Fucoidan uptake was significantly increased in EAM compared with controls starting from D15. There was a close relationship between uptake of the tracer and myocardial content in CD45+, CD8+, CD11b+, and CD31+ cells. CONCLUSIONS [99mTc]Fucoidan SPECT/CT accurately diagnosed the autoimmune attack in the early steps of EAM and could be used to monitor disease evolution and therapy efficiency.
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Dasgupta S, Iannucci G, Mao C, Clabby M, Oster ME. Myocarditis in the pediatric population: A review. CONGENIT HEART DIS 2019; 14:868-877. [DOI: 10.1111/chd.12835] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Glen Iannucci
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Chad Mao
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Martha Clabby
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Matthew E. Oster
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
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117
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Abstract
A 50-year-old male presented to the hospital with an approximate three-week history of nausea, fever, and back pain. Upon initial evaluation he had an electrocardiogram with ischemic changes and initial labs significant for a troponin of >25.0 ng/ml (<0.30 ng/ml), pro b-type natriuretic peptide (proBNP) of 9884 pg/ml (<125 pg/ml), and a lactic acid of 4.3 mmol/L (0.5-1.9 mmol/L). There was a concern for an acute coronary syndrome presenting as cardiogenic shock, but the patient was unable to tolerate left heart catheterization. He had a rapid clinical decline and despite all efforts, he passed away. The initial cause of death was thought to be due to an acute myocardial infarction, however, autopsy results were consistent with acute myocarditis. This case highlights the presentation of acute myocarditis as an acute coronary syndrome with complete heart block.
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Affiliation(s)
| | - Varun Tandon
- Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Manish Kumar
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
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118
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Role of intravenous immunoglobulin therapy in the survival rate of pediatric patients with acute myocarditis: A systematic review and meta-analysis. Sci Rep 2019; 9:10459. [PMID: 31320679 PMCID: PMC6639391 DOI: 10.1038/s41598-019-46888-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 07/08/2019] [Indexed: 01/16/2023] Open
Abstract
The treatment of pediatric myocarditis is controversial, and the benefits of intravenous immunoglobulin (IVIG) are inconclusive due to limited data. We searched studies from PubMed, MEDLINE, Embase, and Cochrane Library databases since establishment until October 1st, 2018. Thirteen studies met the inclusion criteria. We included a total of 812 patients with IVIG treatment and 592 patients without IVIG treatment. The meta-analysis showed that the survival rate in the IVIG group was higher than that in the non-IVIG group (odds ratio = 2.133, 95% confidence interval (CI): 1.32-3.43, p = 0.002). There was moderate statistical heterogeneity among the included studies (I2 = 35%, p = 0.102). However, after adjustment using Duval and Tweedie's trim and fill method, the point estimate of the overall effect size was 1.40 (95% CI 0.83, 2.35), which became insignificant. Moreover, the meta-regression revealed that age (coefficient = -0.191, 95% CI (-0.398, 0.015), p = 0.069) and gender (coefficient = 0.347, 95% CI (-7.586, 8.279), p = 0.93) were not significantly related to the survival rate. This meta-analysis showed that IVIG treatment was not associated with better survival. The use of IVIG therapy in acute myocarditis in children cannot be routinely recommended based on current evidence. Further prospective and randomized controlled studies are needed to elucidate the effects of IVIG treatment.
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119
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Successful Bridge-to-Recovery Treatment in a Young Patient with Fulminant Eosinophilic Myocarditis: Roles of a Percutaneous Ventricular Assist Device and Endomyocardial Biopsy. Case Rep Emerg Med 2019; 2019:8236735. [PMID: 31355017 PMCID: PMC6633872 DOI: 10.1155/2019/8236735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/31/2019] [Accepted: 06/16/2019] [Indexed: 01/05/2023] Open
Abstract
Eosinophilic myocarditis (EM) is a rare condition characterized by myocardial eosinophilic infiltration due to various underlying etiologies. The patient with EM may benefit from appropriate use of mechanical circulatory support (MCS) that acts as a bridge to myocardial recovery in response to effective immunosuppressive therapy. A 16-year-old boy presented with cardiogenic shock due to fulminant myocarditis, for which a percutaneous ventricular assist device (PVAD) was immediately inserted. Based on the histological diagnosis of EM, immunosuppressive therapy was immediately commenced, leading to improvement of left-ventricular ejection fraction (27% to 47%). The PVAD was successfully removed on day 7. Cardiac magnetic resonance imaging and dual-tracer myocardial scintigraphy suggested limited extent of irreversible myocardial damage. For fulminant EM, the short-term use of PVAD, together with immunosuppressive therapy guided by an immediate histological investigation, may be an effective bridging strategy to myocardial recovery.
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120
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Outcome for children following admission to hospital with a first episode of heart failure, due to heart muscle disease, in the ventricular assist device (VAD) era. Cardiol Young 2019; 29:888-892. [PMID: 31298178 DOI: 10.1017/s1047951119001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIMS Most reports on the outcome of children who present with heart failure, due to heart muscle disease, are from an era when ventricular assist devices were not available. This study provides outcome data for the current era where prolonged circulatory support can be considered for most children. METHODS & RESULTS Data was retrieved on 100 consecutive children, who presented between 2010 - 2016, with a first diagnosis of unexplained heart failure. Hospital outcome was classified as either death, transplantation, recovery of function or persistent heart failure. Median age at presentation was 24 months and 58% were < 5 years old. Hospital mortality was 12% and 59% received a heart transplant. Most, 79%, of the transplants were carried out on patients with a device. Recovery of function was observed in 18% and 10% stabilised on oral therapy. Eighty-four percent of the deaths occurred in the <5 year old group. Shorter duration of support was associated with survival (34 days in survivors versus 106 in non-survivors, p = 0.01) and 72% were on an assist device at time of death. CONCLUSION Heart failure in children who require referral to a transplant unit is a serious illness with a high chance of either transplantation or death. Modifications in assist devices will be required to improve safety, especially for children < 5 years old where the donor wait may be prolonged. The identification of children who may recover function requires further study.
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121
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Moslehi JJ, Brinkley DM, Meijers WC. Fulminant Myocarditis. J Am Coll Cardiol 2019; 74:312-314. [DOI: 10.1016/j.jacc.2019.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 11/25/2022]
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122
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Abstract
PURPOSE OF REVIEW The aim of this study is to summarize the literature describing the pathogenesis, diagnosis and management of cardiomyopathy related to myocarditis. RECENT FINDINGS Myocarditis has a variety of causes and a heterogeneous clinical presentation with potentially life-threatening complications. About one-third of patients will develop a dilated cardiomyopathy and the pathogenesis is a multiphase, mutlicompartment process that involves immune activation, including innate immune system triggered proinflammatory cytokines and autoantibodies. In recent years, diagnosis has been aided by advancements in cardiac MRI, and in particular T1 and T2 mapping sequences. In certain clinical situations, endomyocardial biopsy (EMB) should be performed, with consideration of left ventricular sampling, for an accurate diagnosis that may aid treatment and prognostication. SUMMARY Although overall myocarditis accounts for a minority of cardiomyopathy and heart failure presentations, the clinical presentation is variable and the pathophysiology of myocardial damage is unique. Cardiac MRI has significantly improved diagnostic abilities, but endomyocardial biopsy remains the gold standard. However, current treatment strategies are still focused on routine heart failure pharmacotherapies and supportive care or cardiac transplantation/mechanical support for those with end-stage heart failure.
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123
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Błyszczuk P. Myocarditis in Humans and in Experimental Animal Models. Front Cardiovasc Med 2019; 6:64. [PMID: 31157241 PMCID: PMC6532015 DOI: 10.3389/fcvm.2019.00064] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/30/2019] [Indexed: 12/21/2022] Open
Abstract
Myocarditis is defined as an inflammation of the cardiac muscle. In humans, various infectious and non-infectious triggers induce myocarditis with a broad spectrum of histological presentations and clinical symptoms of the disease. Myocarditis often resolves spontaneously, but some patients develop heart failure and require organ transplantation. The need to understand cellular and molecular mechanisms of inflammatory heart diseases led to the development of mouse models for experimental myocarditis. It has been shown that pathogenic agents inducing myocarditis in humans can often trigger the disease in mice. Due to multiple etiologies of inflammatory heart diseases in humans, a number of different experimental approaches have been developed to induce myocarditis in mice. Accordingly, experimental myocarditis in mice can be induced by infection with cardiotropic agents, such as coxsackievirus B3 and protozoan parasite Trypanosoma cruzi or by activating autoimmune responses against heart-specific antigens. In certain models, myocarditis is followed by the phenotype of dilated cardiomyopathy and the end stage of heart failure. This review describes the most commonly used mouse models of experimental myocarditis with a focus on the role of the innate and adaptive immune systems in induction and progression of the disease. The review discusses also advantages and limitations of individual mouse models in the context of the clinical manifestation and the course of the disease in humans. Finally, animal-free alternatives in myocarditis research are outlined.
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Affiliation(s)
- Przemysław Błyszczuk
- Department of Clinical Immunology, Jagiellonian University Medical College, Cracow, Poland.,Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, Zurich, Switzerland
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Ogawa S, Suzuki M, Ochi H, Saji M, Mahara K, Takamisawa I, Nishigawa K, Furuichi Y, Takanashi S, Isobe M. The Clinical Potential of Impella 5.0 Support in the Treatment of Recurrent Fulminant Viral Myocarditis with Profound Cardiogenic Shock. Intern Med 2019; 58:1459-1462. [PMID: 30626823 PMCID: PMC6548930 DOI: 10.2169/internalmedicine.1866-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We herein report the clinical potential of Impella 5.0 support, which is a catheter-mounted micro-axial left ventricular support device, in a 39-year-old man with recurrent fulminant viral myocarditis complicated with profound cardiogenic shock despite inotropic infusion and an intra-aortic balloon pumping. Switching from these therapies to the Impella 5.0 device provided sufficient systemic perfusion with well-controlled left ventricular diastolic properties to facilitate a prompt recovery from profound cardiogenic shock. The patient was uneventfully discharged on the 27th hospital day. Given its effect of cardiac protection with sufficient systemic perfusion, the Impella device should be considered the first-line therapy for the treatment of fulminant myocarditis complicated with cardiogenic shock.
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Affiliation(s)
- Shou Ogawa
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | - Makoto Suzuki
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | - Hiroyuki Ochi
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | - Keitaro Mahara
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | | | - Kosaku Nishigawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Japan
| | - Yuko Furuichi
- Department of Anesthesiology, Sakakibara Heart Institute, Japan
| | | | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute, Japan
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125
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Merken J, Hazebroek M, Van Paassen P, Verdonschot J, Van Empel V, Knackstedt C, Abdul Hamid M, Seiler M, Kolb J, Hoermann P, Ensinger C, Brunner-La Rocca HP, Poelzl G, Heymans S. Immunosuppressive Therapy Improves Both Short- and Long-Term Prognosis in Patients With Virus-Negative Nonfulminant Inflammatory Cardiomyopathy. Circ Heart Fail 2019; 11:e004228. [PMID: 29449368 DOI: 10.1161/circheartfailure.117.004228] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inflammatory cardiomyopathy (infl-CMP) is characterized by increased cardiac inflammation in the absence of viruses, ischemia, valvular disease, or other apparent causes. Studies addressing the efficacy of immunosuppressive therapy in patients with infl-CMP are sparse. This study retrospectively investigates whether immunosuppressive agents on top of heart failure therapy according to current guidelines improves cardiac function and long-term outcome in patients with infl-CMP. METHODS AND RESULTS Within the Innsbruck and Maastricht Cardiomyopathy Registry, a total of 209 patients fulfilled the criteria for infl-CMP using endomyocardial biopsy (≥14 infiltrating inflammatory cells/mm2). A total of 110 (53%) patients received immunosuppressive therapy and 99 (47%) did not. To correct for potential selection bias, 1:1 propensity score matching was used on all significant baseline parameters, resulting in a total of 90 patients per group. Baseline characteristics did not significantly differ between both patient groups, reflecting optimal propensity score matching. After a median follow-up of 31 (15-47) months, immunosuppressive therapy resulted in an improved long-term outcome (eg, heart transplantation-free survival) as compared with standard heart failure therapy alone (Log-rank P=0.043; hazard ratio, 0.34 [95% CI, 0.17-0.92]) and in a significant larger increase of left ventricular ejection fraction after a mean of 12 months follow-up, as compared with patients receiving standard heart failure treatment only (12.2% versus 7.3%, respectively; P=0.036). CONCLUSIONS To conclude, this study suggests that immunosuppressive therapy in infl-CMP patients results in an improved heart transplantation-free survival as compared with standard heart failure therapy alone, underscoring the urgent need for a large prospective multicenter trial.
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Affiliation(s)
- Jort Merken
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria.
| | - Mark Hazebroek
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Pieter Van Paassen
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Job Verdonschot
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Vanessa Van Empel
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Christian Knackstedt
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Myrurgia Abdul Hamid
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Michael Seiler
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Julian Kolb
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Philipp Hoermann
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Christian Ensinger
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Hans-Peter Brunner-La Rocca
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Gerhard Poelzl
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Stephane Heymans
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
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Pahuja M, Adegbala O, Mishra T, Akintoye E, Chehab O, Mony S, Singh M, Ando T, Abubaker H, Yassin A, Subahi A, Shokr M, Ranka S, Briasoulis A, Kapur NK, Burkhoff D, Afonso L. Trends in the Incidence of In-Hospital Mortality, Cardiogenic Shock, and Utilization of Mechanical Circulatory Support Devices in Myocarditis (Analysis of National Inpatient Sample Data, 2005-2014). J Card Fail 2019; 25:457-467. [PMID: 31035007 DOI: 10.1016/j.cardfail.2019.04.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/09/2019] [Accepted: 04/20/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients. METHODS We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged >18 years with myocarditis in the United States. RESULTS The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend <.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend <.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P< .01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P< .01). CONCLUSION Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.
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Affiliation(s)
- Mohit Pahuja
- Division of Cardiology, Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Oluwole Adegbala
- Department of Internal Medicine, Engelwood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Engelwood, New Jersey
| | - Tushar Mishra
- Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Emmanuel Akintoye
- Division of Cardiology, Departement of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa
| | - Omar Chehab
- Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Shruti Mony
- Division of Gastroenterology, University of South Florida, Tampa, Florida
| | - Manmohan Singh
- Division of Cardiology, Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Tomo Ando
- Division of Cardiology, Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Hossam Abubaker
- Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Ahmed Yassin
- Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Ahmed Subahi
- Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Mohamed Shokr
- Division of Cardiology, Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Sagar Ranka
- Department of Internal Medicine, Cook County Hospital, Chicago, Illinios
| | - Alexandros Briasoulis
- Division of Cardiology, Departement of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa
| | - Navin K Kapur
- Division of Cardiology, Department of Internal Medicine, Tufts Medical Center
| | - Daniel Burkhoff
- Cardiovascular Research Foundation; Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
| | - Luis Afonso
- Division of Cardiology, Department of Inernal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan.
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127
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Analysis of clinical parameters and echocardiography as predictors of fatal pediatric myocarditis. PLoS One 2019; 14:e0214087. [PMID: 30893383 PMCID: PMC6426257 DOI: 10.1371/journal.pone.0214087] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Pediatric myocarditis symptoms can be mild or as extreme as sudden cardiac arrest. Early identification of the severity of illness and timely provision of critical care is helpful; however, the risk factors associated with mortality remain unclear and controversial. We undertook a retrospective review of the medical records of pediatric patients with myocarditis in a tertiary care referral hospital for over 12 years to identify the predictive factors of mortality. Demographics, presentation, laboratory test results, echocardiography findings, and treatment outcomes were obtained. Regression analyses revealed the clinical parameters for predicting mortality. During the 12-year period, 94 patients with myocarditis were included. Of these, 16 (17%) patients died, with 12 succumbing in the first 72 hours after admission. Fatal cases more commonly presented with arrhythmia, hypotension, acidosis, gastrointestinal symptoms, decreased left ventricular ejection fraction, and elevated isoenzyme of creatine kinase and troponin I levels than nonfatal cases. In multivariate analysis, troponin I > 45 ng/mL and left ventricular ejection fraction < 42% were significantly associated with mortality. Pediatric myocarditis had a high mortality rate, much of which was concentrated in the first 72 hours after hospitalization. Children with very high troponin levels or reduced ejection fraction in the first 24 hours were at higher risk of mortality, and targeting these individuals for more intensive therapies may be warranted.
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128
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An improved protocol for the treatment of fulminant myocarditis. SCIENCE CHINA-LIFE SCIENCES 2019; 62:433-434. [PMID: 30848420 DOI: 10.1007/s11427-019-9507-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 02/26/2019] [Indexed: 01/26/2023]
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129
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Li S, Xu S, Li C, Ran X, Cui G, He M, Miao K, Zhao C, Yan J, Hui R, Zhou N, Wang Y, Jiang J, Zhang J, Wang D. A life support-based comprehensive treatment regimen dramatically lowers the in-hospital mortality of patients with fulminant myocarditis: a multiple center study. SCIENCE CHINA-LIFE SCIENCES 2019; 62:369-380. [PMID: 30850929 DOI: 10.1007/s11427-018-9501-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/22/2019] [Indexed: 12/20/2022]
Abstract
Fulminant myocarditis (FM) has unacceptable high mortality. This study aimed to evaluate the therapeutic efficacy of a life support-based comprehensive treatment regimen (LSBCTR), a completely novel treatment regimen, for FM. A total of 169 FM patients recruited from January 2008 to December 2018 were divided into two groups: patients receiving LSBCTR (81 cases), which includes (i) mechanical life support (positive pressure respiration, intra-aortic balloon pump with or without extracorporeal membrane oxygenation), (ii) immunomodulation therapy using sufficient doses of glucocorticoids and immunoglobulins, and (iii) application of neuraminidase inhibitors, and those receiving conventional treatment (88 cases). The endpoints were in-hospital death and heart-transplantation. Of all the population, 44 patients (26.0%) died in hospitals. In-hospital mortality was 3.7% (3/81) for LSBCTR group and 46.6% (41/88) for traditional treatment (P<0.001). Early application of LSBCTR, mechanical life support, neuraminidase inhibitors, and immunomodulation therapy significantly contributed to reduction in in-hospital mortality. This study describes a novel treatment regimen for FM patients that dramatically reduces in-hospital mortality. Its generalization and clinical application will efficiently save lives although further optimization is needed. This study offers an insight that virus infection induced inflammatory waterfall results in cardiac injury and cardiogenic shock and is the therapeutic target.
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Affiliation(s)
- Sheng Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Shengyong Xu
- Emergency Department of Union Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Chenze Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Xiao Ran
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Guanglin Cui
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Mengying He
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Kun Miao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Chunxia Zhao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Jiangtao Yan
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Rutai Hui
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Ning Zhou
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Jiangang Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
| | - Jing Zhang
- Fuwai Huazhong Cardiovascular Hospital, Zhengzhou, 451450, China.
| | - Daowen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
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130
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Hopkins KA, Abdou MH, Hadi MA. Coxsackie B2 Virus Infection Causing Multiorgan Failure and Cardiogenic Shock in a 42-Year-Old Man. Tex Heart Inst J 2019; 46:32-35. [PMID: 30833835 DOI: 10.14503/thij-17-6361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Infections from coxsackie B2 viruses often cause viral myocarditis and, only rarely, multisystem organ impairment. We present the unusual case of a 42-year-old man in whom coxsackie B2 virus infection caused multiorgan infection, necessitating distal pancreatectomy, splenectomy, renal dialysis, and venoarterial extracorporeal membrane oxygenation with mechanical ventilation. In addition, the patient had a rapid-eye-movement sleep-related conduction abnormality that caused frequent sinus pauses of longer than 10 s, presumably due to myocarditis from the coxsackievirus infection. He recovered after permanent pacemaker placement and was discharged from the hospital. We discuss our aggressive supportive care and the few other reports of multiorgan impairment from coxsackieviruses.
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131
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Veronese G, Cipriani M, Petrella D, Pedrotti P, Giannattasio C, Garascia A, Oliva F, Klingel K, Frigerio M, Ammirati E. Not every fulminant lymphocytic myocarditis fully recovers. J Cardiovasc Med (Hagerstown) 2019; 19:453-454. [PMID: 29889166 DOI: 10.2459/jcm.0000000000000664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Giacomo Veronese
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda.,Department of Health Science, University of Milano-Bicocca, Milan, Italy
| | - Manlio Cipriani
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Duccio Petrella
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Patrizia Pedrotti
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Cristina Giannattasio
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda.,Department of Health Science, University of Milano-Bicocca, Milan, Italy
| | - Andrea Garascia
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Fabrizio Oliva
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Maria Frigerio
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
| | - Enrico Ammirati
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda
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132
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Affiliation(s)
- Leslie T Cooper
- From Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL.
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133
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Martínez-Mateo V, Fernández-Anguita M, Cejudo L, Martín-Barrios E, Paule AJ. Long-term and clinical profile of heart failure with recovered ejection fraction in a non-tertiary hospital. Med Clin (Barc) 2019; 152:50-54. [PMID: 29884453 DOI: 10.1016/j.medcli.2018.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/29/2018] [Accepted: 05/03/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Heart failure (HF) with recovered ejection fraction (EF) is emerging as a different HF subtype. There is little information about his clinical profile in hospitals that are not a reference. METHODS We analysed characteristics and prognosis in patients with recovered HF followed prospectively in the HF Unit of a non-tertiary hospital. RESULTS A total of 431 patients with HF with reduced EF were followed (median 50 months, 79.3% males, mean age 70.3±12.2years). Of the patients, 26.9% (N 116) recovered EF, mainly in the first year of follow-up (76.7%). Compared with patients that did not recovered EF in the follow-up, they were younger, rate of ischemic origin of cardiomyopathy was less frequent and presented less comorbidity. Mortality was lower in patients with recovered HF (survival median of 85.2±2.1 vs. 74.2±1.9 months [log-rank χ2 11.5, P=0.001], hazard ratio 0.37, 95% confidence interval [CI]: 0.21-0.67, P=0.002). Aetiology of deaths was not mainly secondary to HF. Younger age of 68 years (odds ratio [OR] 0-98, 95% CI: 0.96-0,99; P=0.025), ischemic origin (OR 1.12, 95% CI: 1.01-1.21; P=0.003) and use of aldosterone antagonists (OR 1.89, 95% CI: 1.09-3.26; P=0.023) were the variables independently associated to normalisation of EF. CONCLUSION HF with recovered EF is a frequent phenomenon. It has a more favourable clinical course, prognosis and basal characteristics than HF with persistent reduced EF. Further studies are needed to identify natural history and optimal medications for HF-recovered patients.
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Affiliation(s)
- Virgilio Martínez-Mateo
- Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), España.
| | | | - Laura Cejudo
- Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), España
| | - Eugenia Martín-Barrios
- Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), España
| | - Antonio J Paule
- Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), España
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Abstract
Myocarditis is commonly a diagnosis of exclusion. We report a case of fulminant myocarditis in a patient with cardiogenic shock in whom the initial diagnosis was unclear. Early supportive care including extracorporeal membrane oxygenation and intraaortic balloon pump were instituted. Complete recovery of cardiac function was achieved. This case highlights the difficulty in diagnosing myocarditis and the benefits of early intensive support.
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Affiliation(s)
- W Ahmar
- Departments of Cardiology, The Melbourne Heart Centre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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135
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Gannon MP, Schaub E, Grines CL, Saba SG. State of the art: Evaluation and prognostication of myocarditis using cardiac MRI. J Magn Reson Imaging 2019; 49:e122-e131. [DOI: 10.1002/jmri.26611] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 01/14/2023] Open
Affiliation(s)
- Michael P. Gannon
- National Heart, Lung, and Blood InstituteNational Institutes of Health Bethesda Maryland USA
| | - Ebe Schaub
- University of Heidelberg Heidelberg Germany
| | - Cindy L. Grines
- Department of CardiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
| | - Shahryar G. Saba
- Department of CardiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
- Department of RadiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
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136
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China’s treatment regimen for fulminant myocarditis is bringing wonderful achievement to the world. SCIENCE CHINA-LIFE SCIENCES 2019; 62:282-284. [DOI: 10.1007/s11427-018-9445-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/09/2018] [Indexed: 10/27/2022]
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Kim MS, Lee JH, Cho HJ, Cho JY, Choi JO, Hwang KK, Yoo BS, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity. Korean Circ J 2019; 49:46-68. [PMID: 30637995 PMCID: PMC6331326 DOI: 10.4070/kcj.2018.0351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.
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Affiliation(s)
- Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hyun Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jin Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Kuk Hwang
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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138
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Chinese society of cardiology expert consensus statement on the diagnosis and treatment of adult fulminant myocarditis. SCIENCE CHINA-LIFE SCIENCES 2018; 62:187-202. [PMID: 30519877 PMCID: PMC7102358 DOI: 10.1007/s11427-018-9385-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/02/2018] [Indexed: 01/02/2023]
Abstract
Fulminant 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 mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial (NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time, we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes (i) mechanical life support (applications of mechanical respirators and circulatory support systems, including intraaortic balloon pump and extracorporeal membrane oxygenation, (ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and (iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
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139
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An Out-of-Season Case of Coxsackie B Myocarditis with Severe Rhabdomyolysis. Case Rep Infect Dis 2018; 2018:4258296. [PMID: 30510822 PMCID: PMC6232831 DOI: 10.1155/2018/4258296] [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: 07/02/2018] [Accepted: 09/27/2018] [Indexed: 11/18/2022] Open
Abstract
A 21-year-old woman was found to have fulminant myocarditis as a result of Coxsackie B infection (a virus shown to exhibit summer-fall seasonality) in mid-December. In this case report, seasonality of enteroviruses is examined, as well as additional factors which may contribute to sporadic cases during winter months. The case report also discusses clinical criteria for endomyocardial biopsy, utility of PCR vs. antibody serological tests, coinfection with multiple serotypes, and rhabdomyolysis in Coxsackie B.
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140
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2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2018; 15:e73-e189. [DOI: 10.1016/j.hrthm.2017.10.036] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 02/07/2023]
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141
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Ammirati E, Veronese G, Cipriani M, Moroni F, Garascia A, Brambatti M, Adler ED, Frigerio M. Acute and Fulminant Myocarditis: a Pragmatic Clinical Approach to Diagnosis and Treatment. Curr Cardiol Rep 2018; 20:114. [PMID: 30259175 DOI: 10.1007/s11886-018-1054-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To review the clinical features of acute myocarditis, including its fulminant presentation, and present a pragmatic approach to the diagnosis and treatment, considering indications of American and European Scientific Statements and recent data derived by large contemporary registries. RECENT FINDINGS Patients presenting with acute uncomplicated myocarditis (i.e., without left ventricular dysfunction, heart failure, or ventricular arrhythmias) have a favorable short- and long-term prognosis: these findings do not support the indication to endomyocardial biopsy in this clinical scenario. Conversely, patients with complicated presentations, especially those with fulminant myocarditis, require an aggressive and comprehensive management, including endomyocardial biopsy and availability of advanced therapies for circulatory support. Although several immunomodulatory or immunosuppressive therapies have been studied and are actually prescribed in the real-world practice, their effectiveness has not been clearly demonstrated. Patients with specific histological subtypes of acute myocarditis (i.e., giant cell and eosinophilic myocarditis) or those affected by sarcoidosis or systemic autoimmune disorders seem to benefit most from immunosuppression. On the other hand, no clear evidence supports the use of immunosuppressive agents in patients with lymphocytic acute myocarditis, even though small series suggest a potential benefit. Acute myocarditis is a heterogeneous condition with distinct pathophysiological pathways. Further research is mandatory to identify factors and mechanisms that may trigger/maintain or counteract/repair the myocardial damage, in order to provide a rational for future evidence-based treatment of patients affected by this condition.
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Affiliation(s)
- Enrico Ammirati
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.
| | - Giacomo Veronese
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Manlio Cipriani
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | | | - Andrea Garascia
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Maria Frigerio
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
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142
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2018; 138:e272-e391. [PMID: 29084731 DOI: 10.1161/cir.0000000000000549] [Citation(s) in RCA: 249] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - William G Stevenson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael J Ackerman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - William J Bryant
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - David J Callans
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne B Curtis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Barbara J Deal
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Timm Dickfeld
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael E Field
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Gregg C Fonarow
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne M Gillis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Christopher B Granger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Stephen C Hammill
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Mark A Hlatky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - José A Joglar
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - G Neal Kay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Daniel D Matlock
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Robert J Myerburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Richard L Page
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
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143
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Fenton MJ, Horne P, Simmonds J, Neligan SL, Andrews RE, Burch M. Potential for and timing of recovery in children with dilated cardiomyopathy. Int J Cardiol 2018; 266:162-166. [PMID: 29887441 DOI: 10.1016/j.ijcard.2017.12.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 12/10/2017] [Accepted: 12/20/2017] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Understanding the clinical course and time-frame for recovery is helpful to guide management and counselling following a diagnosis of Dilated Cardiomyopathy (DCM). We aimed to document outcomes and time to recovery for a cohort of patients with a dilated cardiomyopathy phenotype. METHODS An observational cohort methodology was used to collect retrospective data from the departmental database for those identified with DCM. Data relating to mode of presentation, echocardiographic parameters, clinical management and outcome were collated and analysed. Predictors and time-scale for recovery were investigated and reported. RESULTS 209 new referrals were included within the time frame. 82 children median age 1.0years (IQR 3.4) required intensive care (ICU) and their survival without death or transplant was 51% to one year and 45% to five years. 127 children presented to the pediatric heart failure clinic. Excluding 58 with neuromuscular disease, median age was 4.1years (IQR 11.3) & survival without death or transplant 85% to 1year and 50% to 5years. NT-proBNP normalized in survivors before echocardiographic parameters. Predictors of recovery included younger age, female sex and smaller left ventricular end diastolic Z score on echocardiogram at presentation. CONCLUSION Transplant-free survival to one year is significantly better for patients presenting to clinic, but longer-term survival is better amongst those presenting to ICU due to a late attrition in those with less severe heart failure at presentation. Falling NT-proBNP is the earliest marker of recovery. Recovery of cardiac function remains possible up to three years from presentation.
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Affiliation(s)
- Matthew J Fenton
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK.
| | - Philippa Horne
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Jacob Simmonds
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Sophie L Neligan
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Rachel E Andrews
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Michael Burch
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
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144
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A Fatal Case of Influenza B Myocarditis with Cardiac Tamponade. Case Rep Crit Care 2018; 2018:8026314. [PMID: 30245893 PMCID: PMC6136560 DOI: 10.1155/2018/8026314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Influenza B is generally regarded as a less severe counterpart to influenza A, typically causing mild upper respiratory symptoms. Myocardial involvement with influenza B is a rare complication, better described in children than adults. However, when it occurs, it can lead to profound myocarditis with progression to shock requiring aggressive supportive care. Case Presentation We present a case of cardiac tamponade in the setting of influenza B infection in a previously healthy 57-year-old woman, with progression to refractory shock and death. Autopsy revealed myocardial necrosis with infiltration of CD3+ lymphocytes, and little evidence of viral pneumonia. Conclusions Myocarditis is a rare complication of influenza B in adults, and subsequent pericardial effusion with tamponade physiology is a previously unreported event in an otherwise healthy adult without other medical comorbidities. While rare, this is a serious and potentially fatal complication that clinicians should be aware of when evaluating a patient with suspected viral illness who is exhibiting shock physiology.
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145
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72:e91-e220. [PMID: 29097296 DOI: 10.1016/j.jacc.2017.10.054] [Citation(s) in RCA: 683] [Impact Index Per Article: 113.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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146
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Cho Y, Kim SH, Kim YR, Kim YN, Kim JY, Kim TH, Nam GB, Roh SY, Park KM, Park HS, Pak HN, Bae EJ, Oh S, Yoon N, Lee MY, Cho Y, Jin ES, Cha TJ, Choi JI, Kim J. 2018 KHRS Guidelines for Catheter Ablation of Ventricular Arrhythmias – Part3. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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147
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Matsumoto M, Asaumi Y, Nakamura Y, Nakatani T, Nagai T, Kanaya T, Kawakami S, Honda S, Kataoka Y, Nakajima S, Seguchi O, Yanase M, Nishimura K, Miyamoto Y, Kusano K, Anzai T, Noguchi T, Fujita T, Kobayashi J, Ishibashi-Ueda H, Shimokawa H, Yasuda S. Clinical determinants of successful weaning from extracorporeal membrane oxygenation in patients with fulminant myocarditis. ESC Heart Fail 2018; 5:675-684. [PMID: 29757498 PMCID: PMC6073023 DOI: 10.1002/ehf2.12291] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 01/10/2018] [Accepted: 03/17/2018] [Indexed: 11/25/2022] Open
Abstract
Aims Patients with fulminant myocarditis (FM) often present with cardiogenic shock and require mechanical circulatory support, including extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) implantation. This study sought to clarify the determinants of successful weaning from ECMO in FM patients. Methods and results We studied 37 consecutive FM patients supported by ECMO as the initial form of mechanical circulatory support between January 1995 and December 2014 in our hospital. Twenty‐two (59%) patients were successfully weaned from ECMO, while 15 (41%) were not. There were significant differences in levels of peak creatine kinase and those of its MB isoform (CK‐MB), left ventricular posterior wall thickness (LVPWT), and prevalence of cardiac rhythm disturbances. Receiver operating characteristic curve analysis revealed that a peak CK‐MB level of 185 IU/L and LVPWT of 11 mm were the optimal cut‐off values for predicting successful weaning from ECMO (areas under the curve, 0.89 and 0.85, respectively). During the follow‐up [median 48 (interquartile range 8–147) months], 83% of FM patients who were weaned from ECMO survived, with preserved fractional shortening based on echocardiography. Of the 15 FM patients who were not weaned from ECMO, nine bridged to VAD, and only two were successfully weaned from VAD and survived. Conclusions These results indicate that myocardial injury, as evidenced by CK‐MB and LVPWT, and prolonged presence of cardiac rhythm disturbances are important clinical determinants of successful weaning from ECMO.
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Affiliation(s)
- Manabu Matsumoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Department of Innovative Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuichi Nakamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takeshi Nakatani
- Department of Transplantation, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoaki Kanaya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Seiko Nakajima
- Department of Transplantation, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Osamu Seguchi
- Department of Transplantation, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplantation, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Department of Innovative Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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148
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Tanwani J, Tselios K, Gladman DD, Su J, Urowitz MB. Lupus myocarditis: a single center experience and a comparative analysis of observational cohort studies. Lupus 2018; 27:1296-1302. [PMID: 29642752 DOI: 10.1177/0961203318770018] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Lupus myocarditis (LM) is reported in 3-9% of patients with systemic lupus erythematosus (SLE) but limited evidence exists regarding optimal treatment and prognosis. This study aims to describe LM in a defined lupus cohort as compared with the existing literature. Patients and methods Patients with LM were identified from the University of Toronto Lupus Clinic database. Diagnosis was based on clinical manifestations and electrocardiographic, imaging, and biochemical criteria. Demographic, clinical, diagnostic and therapeutic variables and outcomes were collected in a standardized data retrieval form. A literature review was performed to identify cohort studies reporting on LM treatment and outcome. A comparative analysis was conducted between our patients and the combined cohort of the existing studies. Results Thirty patients were diagnosed with LM (prevalence 1.6%) and compared with a cumulative cohort of 117 patients from five distinct studies. No significant differences were found regarding the age at diagnosis (32.6 ± 13.4 years) and SLE duration (2.5 years median). Concomitant lupus activity from other organ systems was observed in 97% of the patients. Chest pain was more frequently reported in our cohort whereas dyspnea was more prominent in the other studies. Diagnostic criteria were similar across studies. Therapeutic approach was comparable and consisted of glucocorticosteroids (96.6%) and immunosuppressives (70%). Mortality was approximately 20% whereas another 20% of the patients achieved partial and 60% complete recovery. Conclusions LM usually occurs early in the disease course and in the context of generalized lupus activity. Despite aggressive therapy, approximately 40% of the patients died or had residual heart damage.
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Affiliation(s)
- J Tanwani
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - K Tselios
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - D D Gladman
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - J Su
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - M B Urowitz
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
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149
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Abstract
Myocarditis is an inflammatory disease of the myocardium with a broad spectrum of clinical presentations, ranging from mild symptoms to severe heart failure. The course of patients with myocarditis is heterogeneous, varying from partial or full clinical recovery in few days to advanced low cardiac output syndrome requiring mechanical circulatory support or heart transplantation. Fulminant myocarditis (FM) is a peculiar clinical condition and is an acute form of myocarditis, whose main characteristic is a rapidly progressive clinical course with the need for hemodynamic support. Despite the common medical belief of the past decades, recent comprehensive data, including a recent registry that compared FM with acute non-FM, highlighted that FM has a poor inhospital outcome, often requires advanced hemodynamic support, and may result in residual left ventricular dysfunction in survivors. This review aimed to provide an updated practical definition of FM, including essentials in the diagnosis and management of the disease. Finally, the outcome of FM was critically revised according to the current published registries focusing on the topic.
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Devkota K, Wang YH, Liu MY, Li Y, Zhang YW. Case Report: III° atrioventricular block due to fulminant myocarditis managed with non-invasive transcutaneous pacing. F1000Res 2018; 7:239. [PMID: 29636901 PMCID: PMC5871802 DOI: 10.12688/f1000research.14000.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2018] [Indexed: 01/31/2023] Open
Abstract
Fulminant myocarditis is a life-threatening clinical condition. It is the inflammation of myocardium leading to acute heart failure, cardiogenic shock and cardiac arrhythmias. Incidence of fulminant myocarditis is low and mortality is high. Most grievous complications of fulminant myocarditis is mainly cardiac arrhythmias; if there is delay on active management of the patient, it may be fatal. Here, we describe a case of III° atrioventricular block due to fulminant myocarditis that was managed with non-invasive transcutaneous cardiac pacing in the absence of ECMO. The non-invasive transcutaneous pacemaker is a safe, effective and convenient device to revert arrhythmias.
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Affiliation(s)
- Kiran Devkota
- Department of Pediatrics I, Renmin Hospital, Hubei University of Medicine, Hubei, China
| | - Ya Hong Wang
- Department of Pediatrics I, Renmin Hospital, Hubei University of Medicine, Hubei, China
| | - Meng Yi Liu
- Department of Pediatrics I, Renmin Hospital, Hubei University of Medicine, Hubei, China
| | - Yan Li
- Department of Pediatrics I, Renmin Hospital, Hubei University of Medicine, Hubei, China
| | - You Wei Zhang
- Department of Pediatrics I, Renmin Hospital, Hubei University of Medicine, Hubei, China
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