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Zhang J, Luo S, Qi L, Xu S, Yi D, Jiang Y, Kong X, Liu T, Dou W, Cai J, Zhang LJ. Cardiovascular magnetic resonance feature tracking derived strain analysis can predict return to training following exertional heatstroke. J Cardiovasc Magn Reson 2024; 26:101076. [PMID: 39098574 PMCID: PMC11417221 DOI: 10.1016/j.jocmr.2024.101076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Exertional heatstroke (EHS) is increasingly common in young trained soldiers. However, prognostic markers in EHS patients remain unclear. The objective of this study was to evaluate cardiovascular magnetic resonance (CMR) feature tracking derived left ventricle (LV) strain as a biomarker for return to training (RTT) in trained soldiers with EHS. METHODS Trained soldiers (participants) with EHS underwent CMR cine sequences between June 2020 and August 2023. Two-dimensional (2D) LV strain parameters were derived. At 3 months after index CMR, the participants with persistent cardiac symptoms including chest pain, dyspnea, palpitations, syncope, and recurrent heat-related illness were defined as non-RTT. Multivariable logistic regression analysis was used to develop a predictive RTT model. The performance of different models was compared using the area under curve (AUC). RESULTS A total of 80 participants (median age, 21 years; interquartile range (IQR), 20-23 years) and 27 health controls (median age, 21 years; IQR, 20-22 years) were prospectively included. Of the 77 participants, 32 had persistent cardiac symptoms and were not able to RTT at 3 months follow-up after experiencing EHS. The 2D global longitudinal strain (GLS) was significantly impaired in EHS participants compared to the healthy control group (-15.8 ± 1.7% vs -16.9 ± 1.2%, P = 0.001), which also showed significant statistical differences between participants with RTT and non-RTT (-15.0 ± 3.5% vs -16.5 ± 1.4%, P < 0.001). 2D-GLS (≤ -15.0%) (odds ratio, 1.53; 95% confidence interval: 1.08, 2.17; P = 0.016) was an independent predictor for RTT even after adjusting known risk factors. 2D-GLS provided incremental prognostic value over the clinical model and conventional CMR parameters model (AUCs: 0.72 vs 0.88, P = 0.013; 0.79 vs 0.88, P = 0.023; respectively). CONCLUSION Two-dimensional global longitudinal strain (≤ -15.0%) is an incremental prognostic CMR biomarker to predict RTT in soldiers suffering from EHS.
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Affiliation(s)
- Jun Zhang
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Song Luo
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Li Qi
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Shutian Xu
- National Clinical Research Centre of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Dongna Yi
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Yue Jiang
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Xiang Kong
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Tongyuan Liu
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China
| | - Weiqiang Dou
- MR Research, GE Healthcare, 100076, Beijing, China
| | - Jun Cai
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China.
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 Jiangsu, China.
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Li X, Sun L, Xi S, Hu Y, Yu Z, Liu H, Sun H, Jing W, Yuan L, Liu H, Li T. V-A ECMO for neonatal coxsackievirus B fulminant myocarditis: a case report and literature review. Front Cardiovasc Med 2024; 11:1364289. [PMID: 38836060 PMCID: PMC11148355 DOI: 10.3389/fcvm.2024.1364289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/09/2024] [Indexed: 06/06/2024] Open
Abstract
Background Neonatal (enteroviral) myocarditis (NM/NEM) is rare but unpredictable and devastating, with high mortality and morbidity. We report a case of neonatal coxsackievirus B (CVB) fulminant myocarditis successfully treated with veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Case presentation A previously healthy 7-day-old boy presented with fever for 4 days. Progressive cardiac dysfunction (weak heart sounds, hepatomegaly, pulmonary edema, ascites, and oliguria), decreased left ventricular ejection fraction (LVEF) and fractional shortening (FS), transient ventricular fibrillation, dramatically elevated creatine kinase-MB (405.8 U/L), cardiac troponin I (25.85 ng/ml), and N-terminal pro-brain natriuretic peptide (NT-proBNP > 35,000 ng/L), and positive blood CVB ribonucleic acid indicated neonatal CVB fulminating myocarditis. It was refractory to mechanical ventilation, fluid resuscitation, inotropes, corticosteroids, intravenous immunoglobulin, and diuretics during the first 4 days of hospitalization (DOH 1-4). The deterioration was suppressed by V-A ECMO in the next 5 days (DOH 5-9), despite the occurrence of bilateral grade III intraventricular hemorrhage on DOH 7. Within the first 4 days after ECMO decannulation (DOH 10-13), he continued to improve with withdrawal of mechanical ventilation, LVEF > 60%, and FS > 30%. In the subsequent 4 days (DOH 14-17), his LVEF and FS decreased to 52% and 25%, and further dropped to 37%-38% and 17% over the next 2 days (DOH 18-19), respectively. There was no other deterioration except for cardiomegaly and paroxysmal tachypnea. Through strengthening fluid restriction and diuresis, and improving cardiopulmonary function, he restabilized. Finally, notwithstanding NT-proBNP elevation (>35,000 ng/L), cardiomegaly, and low LVEF (40%-44%) and FS (18%-21%) levels, he was discharged on DOH 26 with oral medications discontinued within 3 weeks postdischarge. In nearly three years of follow-up, he was uneventful, with interventricular septum hyperechogenic foci and mild mitral/tricuspid regurgitation. Conclusions Dynamic cardiac function monitoring via real-time echocardiography is useful for the diagnosis and treatment of NM/NEM. As a lifesaving therapy, ECMO may improve the survival rate of patients with NM/NEM. However, the "honeymoon period" after ECMO may cause the illusion of recovery. Regardless of whether the survivors of NM/NEM have undergone ECMO, close long-term follow-up is paramount to the prompt identification and intervention of abnormalities.
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Affiliation(s)
- Xingchao Li
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Li Sun
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Shibing Xi
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Yaofei Hu
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Zhongqin Yu
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Hui Liu
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Hui Sun
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Weili Jing
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Li Yuan
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Hongyan Liu
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Tao Li
- Department of Pediatrics, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Hubei University of Medicine, Shiyan, Hubei Province, China
- Institute of Pediatric Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
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Trimarchi G, Teresi L, Licordari R, Pingitore A, Pizzino F, Grimaldi P, Calabrò D, Liotta P, Micari A, de Gregorio C, Di Bella G. Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers. Biomedicines 2024; 12:1051. [PMID: 38791012 PMCID: PMC11117605 DOI: 10.3390/biomedicines12051051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.
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Affiliation(s)
- Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Lucio Teresi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Roberto Licordari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy; (R.L.); (A.M.)
| | - Alessandro Pingitore
- Istituto di Fisiologia Clinica, Clinical Physiology Institute, CNR, 56124 Pisa, Italy;
| | - Fausto Pizzino
- Cardiology Unit, Heart Centre, Fondazione Gabriele Monasterio—Regione Toscana, 54100 Massa, Italy;
| | - Patrizia Grimaldi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Danila Calabrò
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Paolo Liotta
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy; (R.L.); (A.M.)
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
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Yakhshimurodov U, Yamashita K, Kawamura T, Kawamura M, Miyagawa S. Paradigm shift in myocarditis treatment. J Cardiol 2024; 83:201-210. [PMID: 37597837 DOI: 10.1016/j.jjcc.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
Although most cases of myocarditis are self-limiting with a gradual improvement in cardiac function, the involvement of myocarditis in sudden cardiac death among children and young adults remains substantial, with rates of 3-17 % and 8.6-12 %, respectively. Moreover, the risk of developing chronic dilated cardiomyopathy ranges from 21 % to 30 % in all cases confirmed by biopsy. Current therapeutic strategies for myocarditis and its complications range from standard supportive care for heart failure and arrhythmias to etiologically oriented, case-based therapeutic options. For example, immunosuppression is indicated only in certain forms of acute myocarditis with clinical or endomyocardial biopsy evidence of immune checkpoint inhibitor-induced myocarditis and autoimmune diseases, including giant cell myocarditis, eosinophilic myocarditis, vasculitis, or cardiac sarcoidosis. However, our views on myocarditis treatment have changed considerably over the past two decades, thanks to the emergence of regenerative cells/tissues as well as drug and gene delivery systems. Cell-based therapies are now growing in popularity in any field of medicine. Studies evaluating the therapeutic efficacy of different stem cells in the treatment of acute myocarditis and its chronic complications have shown that although the experimental characteristics varied from study to study, in general, these strategies reduced inflammation and myocardial fibrosis while preventing myocarditis-induced systolic dysfunction and adverse remodeling in animal models.
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Affiliation(s)
- Ulugbek Yakhshimurodov
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kizuku Yamashita
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masashi Kawamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Khanna S, Li C, Amarasekera AT, Bhat A, Chen HHL, Gan GCH, Tan TC. Echocardiographic parameters of cardiac structure and function in the diagnosis of acute myocarditis in adult patients: A systematic review and meta-analysis. Echocardiography 2024; 41:e15760. [PMID: 38345413 DOI: 10.1111/echo.15760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/06/2024] [Accepted: 01/06/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Transthoracic echocardiography (TTE) plays a key role in the initial work-up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of myocarditis in adult populations. METHODS A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta-analyzed using a random-effects model for effect size, and assessed through standardized mean difference (SMD). RESULTS Available data from six studies (with a pooled total of 269 myocarditis patients and 240 controls) revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end-diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) (p ≤ .01 for all). LV-GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46-1.98|). Two studies also demonstrated that impairment in LV-GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF. CONCLUSIONS LV-GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population. HIGHTLIGHTS What is already known on this subject? Myocarditis is a disease process that is often a diagnosis of exclusion, as it frequently mimics other acute cardiac pathologies. Transthoracic echocardiography is traditionally the initial imaging modality used for noninvasive structural assessment in populations with myocarditis. What might this study add? This study demonstrates that left ventricular (LV) global longitudinal strain, LV ejection fraction and LV end-diastolic diameter can differentiate between myocarditis patients and healthy controls. LV-GLS demonstrated the greatest overall effect size when comparing these two populations, in comparison to the other measures. How might this impact on clinical practice? This study demonstrates that assessment of myocardial deformation indices allows for sensitive discrimination between myocarditis patients from healthy controls. Routine assessment of LV-GLS may serve as an important diagnostic tool in the acute care setting.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Cindy Li
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Anjalee T Amarasekera
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
- Westmead Hospital, Faculty of Cardiology, University of Sydney, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
- Westmead Hospital, Faculty of Cardiology, University of Sydney, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
- Westmead Hospital, Faculty of Cardiology, University of Sydney, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
- Westmead Hospital, Faculty of Cardiology, University of Sydney, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
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Khanna S, Bhat A, Chen HHL, Gu KH, Amarasekera A, Gan GCH, Nunes MCP, Tan TC. Characterization of Subclinical Cardiac Dysfunction by Speckle Tracking Echocardiography in Patients With Non-severe Acute-Phase Myocarditis. Am J Cardiol 2023; 207:285-291. [PMID: 37769573 DOI: 10.1016/j.amjcard.2023.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 10/03/2023]
Abstract
Subclinical changes in left ventricular (LV) function have been demonstrated in patients with acute-phase myocarditis (AM) despite normal LV ejection fraction. The impact of AM on right ventricular (RV) and left atrial (LA) function has not been well described. This study aimed to assess for subclinical chamber dysfunction by speckle tracking echocardiography and its clinical relevance in this population. Patients with a diagnosis of AM (as per the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases) admitted to our institution from 2013 to 2018 were assessed. Patients with elevated serum troponin, normal coronary assessment, and normal LV ejection fraction on transthoracic echocardiogram were included. Clinical and echocardiographic parameters were compared with healthy age-, gender- and risk-factor matched controls. Global longitudinal strain assessed through speckle tracking echocardiography was performed using vendor independent software (v4.6; TomTec Arena, Munich, Germany). The final cohort consisted of 80 patients (40 AM patients and 40 controls). No significant differences in baseline clinical characteristics were observed between groups. Of the echocardiographic parameters, AM patients had lower LV-global longitudinal strain (p <0.01), lower RV free-wall strain (p = 0.02) and lower peak LA strain (p <0.01). There were no differences in traditional echocardiographic measures of LV, RV, and LA function appreciated between groups. The presence of multichamber involvement was associated with peak Troponin levels (p <0.01). In conclusion, our study demonstrates the presence of global subclinical myocardial dysfunction in patients with AM. Additionally, the presence of multichamber involvement was significantly associated with degree of myocardial necrosis.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Western Sydney University, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
| | - Kennith H Gu
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | | | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Western Sydney University, Sydney, New South Wales, Australia
| | - Maria Carmo P Nunes
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Western Sydney University, Sydney, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia.
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Sandeep M, Padhi BK, Yella SST, Sruthi KG, Venkatesan RG, Krishna Sasanka KBS, Satapathy P, Mohanty A, Al-Tawfiq JA, Iqhrammullah M, Rabaan AA, Kabi A, Sah S, Rustagi S, Al-Qaim ZH, Barboza JJ, Waheed Y, Harapan H, Sah R. Myocarditis manifestations in dengue cases: A systematic review and meta-analysis. J Infect Public Health 2023; 16:1761-1768. [PMID: 37738692 DOI: 10.1016/j.jiph.2023.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Dengue fever is a zoonotic viral infection that raises a global alarm in the tropics and subtropics, with the potentially escalating into newer geographical regions. Severe dengue may be associated with fatal complications such as myocarditis. There is a paucity of available data on the prevalence of dengue-associated myocarditis. The objective of this systematic review and meta-analysis was to estimate the global prevalence of dengue-associated myocarditis. METHODS A systematic search was conducted utilizing the Cochrane library, PubMed, Scopus, ProQuest, Web of Science, and Preprint servers such as arXiv, medRxiv, bioRxiv, BioRN, ChiRN, ChiRxiv, and SSRN as of November 25, 2022. All primary studies (case series, cross-sectional, retrospective, and prospective) that reported confirmed cases of dengue myocarditis were included. The I2 statistic test assessed the heterogenic characteristics and publication bias was evaluated using Doi plot and Egger regression tests. RESULTS A total of 12 studies conducted between 2007 and 2022 with 2795 laboratory-confirmed dengue patients were included. Of the included cases, 502 were positive for myocarditis, with a prevalence of 2.4-78%. The pooled prevalence of dengue-induced myocarditis in the studied population was 21.0% (95% CI, 9 - 38%). The prediction interval was estimated to be 0.00 - 0.81. CONCLUSION Myocarditis in dengue patients is a significant and understudied complication in many aspects. To prevent dengue-associated myocarditis, appropriate measures such as early detection of cases and signs, symptoms-based diagnosis via electrocardiography and echocardiography, as well as relevant vector control policies must be implemented.
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Affiliation(s)
| | - Bijaya K Padhi
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - K G Sruthi
- Department of Oral Medicine and Radiology, KLE VK Institute of Dental Sciences, Hyderabad, India
| | | | | | - Prakasini Satapathy
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aroop Mohanty
- Department of Clinical Microbiology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Jaffar A Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, and Quality and Patient Safety Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | - Muhammad Iqhrammullah
- Faculty of Public Health, Universitas Muhammadiyah Aceh, Banda Aceh 23245, Indonesia; Innovative Sustainability Lab, PT. Biham Riset dan Edukasi, Banda Aceh 23243, Indonesia
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; Department of Public Health and Nutrition, The University of Haripur, Haripur 22610, Pakistan
| | - Ankita Kabi
- Department of Anaesthesia and Critical Care, AIIMS Gorakhpur, Uttar Pradesh 273008, India
| | - Sanjit Sah
- Research Scientist, Global Consortium for Public Health and Research, Datta Meghe Institute of Higher Education and Research, Jawaharlal Nehru Medical College, Wardha 442001, India; SR Sanjeevani Hospital, Kalyanpur-11, Siraha, Nepal
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Uttaranchal University, Dehradun, Uttarakhand, India
| | - Zahraa Haleem Al-Qaim
- Department of Anesthesia Techniques, Al-Mustaqbal University College, 51001 Hilla, Babylon, Iraq
| | - Joshuan J Barboza
- Escuela de Medicina, Universidad César Vallejo, Trujillo 13007, Peru.
| | - Yasir Waheed
- Office of Research, Innovation, and Commercialization (ORIC), Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad 44000, Pakistan; Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos 1401, Lebanon
| | - Harapan Harapan
- Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh 23111, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh 23111, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh 23111, Indonesia; Tsunami and Disaster Mitigation Research Center (TDMRC), Universitas Syiah Kuala, Banda Aceh 23111, Indonesia
| | - Ranjit Sah
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal; Department of Clinical Microbiology, Dr.D.Y Patil Medical College, Hospital and Research Centre, D.Y Patil Vidyapeeth, Pune 411000, India; Department of Public Health Dentistry, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pune 411018, Maharashtra, India.
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Małek ŁA, Śpiewak M. Isolated myocardial edema in cardiac magnetic resonance - in search of a management strategy. Trends Cardiovasc Med 2023; 33:395-402. [PMID: 35405307 DOI: 10.1016/j.tcm.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 04/01/2022] [Indexed: 01/04/2023]
Abstract
Isolated myocardial edema not accompanied by late gadolinium enhancement (LGE) may be occasionally found on cardiac magnetic resonance (CMR). This type of picture may be encountered in patients with suspected myocarditis, post some acute cardiac events, with cardiac allograft rejection or even in athletes after an extreme exercise. Currently, there is no clear management strategy for this type of incidental finding. In this narrative review we discuss the methods and pitfalls of edema detection with means of CMR, review published data on isolated myocardial edema for each of the most probable clinical scenarios and propose a structured clinical decision-making algorithm to help clinicians navigate through this type of CMR result. Finally, we highlight the most important gaps in evidence related to isolated myocardial edema without fibrosis, where further research is particularly needed.
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Affiliation(s)
- Łukasz A Małek
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland.
| | - Mateusz Śpiewak
- Magnetic Resonance Unit, Department of Radiology, National Institute of Cardiology, Warsaw, Poland
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9
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Kang N, Friedrich MG, Abramov D, Martinez-Naharro A, Fontana M, Parwani P. Viral Myocarditis and Dilated Cardiomyopathy as a Consequence-Changing Insights from Advanced Imaging. Heart Fail Clin 2023; 19:445-459. [PMID: 37714586 DOI: 10.1016/j.hfc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Advancements in quantitative cardiac magnetic resonance (CMR) have revolutionized the diagnosis and management of viral myocarditis. With the addition of T1 and T2 mapping parameters in the updated Lake Louise Criteria, CMR can diagnose myocarditis with superior diagnostic accuracy compared with endomyocardial biopsy, especially in stable patients. Additionally, the unique value of CMR tissue characterization continues to improve the diagnosis and risk stratification of myocarditis. This review will discuss new and ongoing developments in cardiovascular imaging and its application to noninvasive diagnosis, prognostication, and management of viral myocarditis and its complications.
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Affiliation(s)
- Nicolas Kang
- Department of Medicine, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA
| | - Matthias G Friedrich
- Department of Medicine, McGill University Health Centre, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada; Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dmitry Abramov
- Division of Cardiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA
| | - Ana Martinez-Naharro
- UCL CMR Department at the Royal Free Hospital and the National Amyloidosis Centre, University College, London
| | - Marianna Fontana
- UCL CMR Department at the Royal Free Hospital and the National Amyloidosis Centre, University College, London
| | - Purvi Parwani
- Division of Cardiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA.
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10
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Tunthong R, Salama AA, Lane CM, Fine NM, Anand V, Padang R, Thaden JJ, Pislaru SV, Kane GC. Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction. J Echocardiogr 2023; 21:105-112. [PMID: 36451073 DOI: 10.1007/s12574-022-00593-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/22/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Right ventricular (RV) systolic function is the major determinant of prognosis in patients with pulmonary hypertension (PH) with quantitative assessment by speckle-tracking strain echocardiography emerging as a viable candidate measure. METHOD We evaluated a prospective cohort of 231 patients with known or suspected PH referred for clinical echocardiography. All underwent measurement of RV free-wall systolic strain by sonographer staff. Digital images were recorded for blinded offline assessment by an expert echocardiographer. Reproducibility was assessed using the analysis methods of Bland-Altman and the Cohen's-Kappa coefficient. RESULTS RV strain was feasible in 213 (92%). The average RV systolic pressure was 59 ± 22 mmHg. RV systolic strain correlated with functional class, NT-proBNP, and the degree of RV enlargement. The average free-wall systolic strain was - 20 ± 7% (range - 2 to - 37%). The RV strain measures (clinical practice versus blinded expert) had an excellent correlation with a normal distribution (R2 0.87, p < 0.0001). By Bland-Altman analysis, the mean difference in measurement was - 1.7% (95% CI - 1.4 to - 2.1) with a correlation of 0.93, p value of < 0.0001. The reproducibility of RV strain for clinically relevant thresholds was also excellent (Kappa coefficients 0.68-0.83). There was no effect on the variability of strain measures across body mass, pulmonary pressures, or rhythm. RV strain correlated with RV diastolic volumes and ejection fraction with RV free wall strain being the best echo predictor for a reduction in ejection fraction. CONCLUSION Here RV systolic strain was found to be highly feasible and reproducible in clinical practice with excellent levels of agreement for clinically relevant thresholds.
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Affiliation(s)
- Ramaimon Tunthong
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Non-Invasive Cardiology Department, Bangkok Hospital Headquarters, BDMS, Bangkok, Thailand
| | - Abdalla A Salama
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Conor M Lane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nowell M Fine
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Vidhu Anand
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA.
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11
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Bobbio E, Amundsen J, Oldfors A, Bollano E, Bergh N, Björkenstam M, Astengo M, Karason K, Gao SA, Polte CL. Echocardiography in inflammatory heart disease: A comparison of giant cell myocarditis, cardiac sarcoidosis, and acute non-fulminant myocarditis. IJC HEART & VASCULATURE 2023; 46:101202. [PMID: 37091913 PMCID: PMC10120371 DOI: 10.1016/j.ijcha.2023.101202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
Background Giant cell myocarditis (GCM) and cardiac sarcoidosis (CS) are, in contrast to acute non-fulminant myocarditis (ANFM), rare inflammatory diseases of the myocardium with poor prognosis. Although echocardiography is the first-line diagnostic tool in these patients, their echocardiographic appearance has so far not been systematically studied. Methods We assessed a total of 71 patients with endomyocardial biopsy-proven GCM (n = 21), and CS (n = 25), as well as magnetic resonance-verified ANFM (n = 25). All echocardiographic examinations, performed upon clinical presentation, were reanalysed according to current guidelines including a detailed assessment of right ventricular (RV) dysfunction. Results In comparison with ANFM, patients with either GCM or CS were older (mean age (±SD) 55 ± 12 or 53 ± 8 vs 25 ± 8 years), more often of female gender (52% or 24% vs 8%), had more severe clinical symptoms and higher natriuretic peptide levels. For both GCM and CS, echocardiography revealed more frequently signs of left ventricular (LV) dysfunction in form of a reduced ejection fraction (p < 0.001), decreased cardiac index (p < 0.001) and lower global longitudinal strain (p < 0.001) in contrast to ANFM. The most prominent increase in LV end-diastolic volume index was observed in CS. In addition, RV dysfunction was more frequently found in both GCM and CS than in ANFM (p = 0.042). Conclusions Both GCM and CS have an echocardiographic and clinical appearance that is distinct from ANFM. However, the method cannot further differentiate between the two rare entities. Consequently, echocardiography can strengthen the initial clinical suspicion of a more severe form of myocarditis, thus warranting a more rigorous clinical work-up.
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Affiliation(s)
- Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Johanna Amundsen
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Oldfors
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Biomedicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Niklas Bergh
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Marie Björkenstam
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Marco Astengo
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Sinsia A. Gao
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Christian L. Polte
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Corresponding author at: Department of Clinical Physiology, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden.
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12
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Mandoli GE, Cameli M, Pastore MC, Benfari G, Malagoli A, D'Andrea A, Sperlongano S, Bandera F, Esposito R, Santoro C, Pedrinelli R, Mercuro G, Indolfi C. Speckle tracking echocardiography in early disease stages: a therapy modifier? J Cardiovasc Med (Hagerstown) 2023; 24:e55-e66. [PMID: 37052222 DOI: 10.2459/jcm.0000000000001422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Echocardiography has been included as a first-line tool in several international guidelines for the management of patients with various cardiac diseases. Beyond diagnosis, echocardiographic examination helps in characterizing the severity of the condition since the very first stages. In particular, the application of second-level techniques, speckle tracking echocardiography in particular, can also reveal a subclinical dysfunction, while the standard parameters are in the normality range. The present review describes the potentialities of advanced echocardiography in different settings, including arterial hypertension, atrial fibrillation, diastolic dysfunction, and oncological patients, thus opening up potential starting points for its application as a clinical routine changer.
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Affiliation(s)
- Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, University of Modena and Reggio Emilia, Modena
| | | | - Simona Sperlongano
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, Naples
| | - Francesco Bandera
- Department of Biomedical Sciences for Health, University of Milano
- Cardiology University Department, IRCCS Policlinico San Donato, Milan
| | | | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital, Naples
| | - Roberto Pedrinelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
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13
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Marschner CA, Shaw KE, Tijmes FS, Fronza M, Khullar S, Seidman MA, Thavendiranathan P, Udell JA, Wald RM, Hanneman K. Myocarditis Following COVID-19 Vaccination. Heart Fail Clin 2023; 19:251-264. [PMID: 36863817 PMCID: PMC9973554 DOI: 10.1016/j.hfc.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Myocarditis is an established but rare adverse event following administration of messenger RNA-based coronavirus disease 2019 (COVID-19) vaccines and is most common in male adolescents and young adults. Symptoms typically develop within a few days of vaccine administration. Most patients have mild abnormalities on cardiac imaging with rapid clinical improvement with standard treatment. However, longer term follow-up is needed to determine whether imaging abnormalities persist, to evaluate for adverse outcomes, and to understand the risk associated with subsequent vaccination. The purpose of the review is to evaluate the current literature related to myocarditis following COVID-19 vaccination, including the incidence, risk factors, clinical course, imaging findings, and proposed pathophysiologic mechanisms.
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Affiliation(s)
- Constantin A Marschner
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada; Department of Radiology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Kirsten E Shaw
- Department of Graduate Medical Education, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA
| | - Felipe Sanchez Tijmes
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada; Department of Medical Imaging, Clinica Santa Maria, Universidad de los Andes, Santa Maria 500, Santiago, Chile 7520378
| | - Matteo Fronza
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada
| | - Sharmila Khullar
- Department of Laboratory Medicine & Pathobiology, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada; Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11E-444, Toronto, Ontario M5G 2C4, Canada
| | - Michael A Seidman
- Department of Laboratory Medicine & Pathobiology, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada; Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11E-444, Toronto, Ontario M5G 2C4, Canada
| | - Paaladinesh Thavendiranathan
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada; Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network (UHN), University of Toronto, 4N-490, 585 University Avenue, Toronto, Ontario M5G2N2, Canada
| | - Jacob A Udell
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network (UHN), University of Toronto, 4N-490, 585 University Avenue, Toronto, Ontario M5G2N2, Canada; Cardiovascular Division, Women's College Hospital, University of Toronto, 76 Grenville Street, Room 6324, Toronto, Ontario M5G2N2, Canada
| | - Rachel M Wald
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada; Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network (UHN), University of Toronto, 5N-517, 585 University Avenue, Toronto, Ontario M5G2N2, Canada
| | - Kate Hanneman
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada.
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14
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Gao Q, Yi W, Gao C, Qi T, Li L, Xie K, Zhao W, Chen W. Cardiac magnetic resonance feature tracking myocardial strain analysis in suspected acute myocarditis: diagnostic value and association with severity of myocardial injury. BMC Cardiovasc Disord 2023; 23:162. [PMID: 36977995 PMCID: PMC10053471 DOI: 10.1186/s12872-023-03201-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/23/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Albeit that cardiac magnetic resonance feature tracking (CMR-FT) has enabled quantitative assessment of global myocardial strain in the diagnosis of suspected acute myocarditis, the cardiac segmental dysfunction remains understudied. The aim of the present study was using CMR-FT to assess the global and segmental dysfunction of the myocardium for diagnosis of suspected acute myocarditis. METHODS Forty-seven patients with suspected acute myocarditis (divided into impaired and preserved left ventricular ejection fraction [LVEF] groups) and 39 healthy controls (HCs) were studied. A total of 752 segments were divided into three subgroups, including segments with non-involvement (SNi), segments with edema (SE), and segments with both edema and late gadolinium enhancement (SE+LGE). 272 healthy segments served as the control group (SHCs). RESULTS Compared with HCs, patients with preserved LVEF showed impaired global circumferential strain (GCS) and global longitudinal strain (GLS). Segmental strain analysis showed that the peak radial strain (PRS), peak circumferential strain (PCS), and peak longitudinal strain (PLS) values significantly reduced in SE+LGE compared with SHCs, SNi, SE. PCS significantly reduced in SNi (-15.3 ± 5.8% vs. -20.3 ± 6.4%, p < 0.001) and SE (-15.2 ± 5.6% vs. -20.3 ± 6.4%, p < 0.001), compared with SHCs. The area under the curve (AUC) values of GLS (0.723) and GCS (0.710) were higher than that of global peak radial strain (0.657) in the diagnosis of acute myocarditis, but the difference was not statistically significant. Adding the Lake Louise Criteria to the model resulted in a further increase in diagnostic performance. CONCLUSIONS Global and segmental myocardial strain were impaired in patients with suspected acute myocarditis, even in the edema or relatively non-involved regions. CMR-FT may serve as an incremental tool for assessment of cardiac dysfunction and provide important additional imaging-evidence for distinguishing the different severity of myocardial injury in myocarditis.
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Affiliation(s)
- Qian Gao
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Wenfang Yi
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Chao Gao
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Tianfu Qi
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Lili Li
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Kaipeng Xie
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Wei Zhao
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China
| | - Wei Chen
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, 295, Xichang Road, Wuhua District, Kunming, 650032, Yunnan Province, Republic of China.
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15
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Hutt E, Kaur S, Jaber WA. Modern tools in cardiac imaging to assess myocardial inflammation and infection. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead019. [PMID: 37006410 PMCID: PMC10063223 DOI: 10.1093/ehjopen/oead019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/27/2023] [Accepted: 03/01/2023] [Indexed: 03/07/2023]
Abstract
Myocardial forms of infection and inflammation are highly heterogeneous in clinical course and presentation but associated with diagnostic and treatment uncertainty, high morbidity, mortality, and financial burden. Historically, these pathologies were diagnosed invasively with biopsy, surgical pathology, or explanted hearts. However, in the current era, the diagnosis has been aided by a variety of non-invasive imaging tools in the appropriate clinical presentation. This review provides a comprehensive understanding of the available imaging modalities for guiding the diagnosis, treatment, and prognosis of cardiac infection and inflammation.
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Affiliation(s)
- Erika Hutt
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Simrat Kaur
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
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16
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Urzua Fresno C, Sanchez Tijmes F, Shaw KE, Huang F, Thavendiranathan P, Khullar S, Seidman MA, Hanneman K. Cardiac Imaging in Myocarditis: Current Evidence and Future Directions. Can Assoc Radiol J 2023; 74:147-159. [PMID: 36062360 DOI: 10.1177/08465371221119713] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Myocarditis is defined as a non-ischemic inflammatory disease of the myocardium. It remains a challenge to diagnose given non-specific symptoms and lack of specific blood biomarkers. Cardiac imaging plays an important role in the evaluation of myocarditis with unique strengths and limitations of different imaging modalities, including cardiac magnetic resonance imaging, echocardiography, cardiac computed tomography, and positron emission tomography. The purpose of this review is to discuss the strengths and limitations of various cardiac imaging techniques in the evaluation of myocarditis, review imaging findings in specific causes of myocarditis including COVID-19 and after vaccination, evaluate the role of imaging in differentiating myocarditis from potential mimics and differential considerations, identify current gaps in knowledge, and propose future directions.
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Affiliation(s)
- Camila Urzua Fresno
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada
| | - Felipe Sanchez Tijmes
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, Clinica Santa Maria, 33179Universidad de los Andes, Santiago, Chile
| | - Kirsten E Shaw
- Department of Cardiology, 123769Hennepin Healthcare/Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Flora Huang
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Paaladinesh Thavendiranathan
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada
| | - Sharmila Khullar
- Department of Laboratory Medicine & Pathobiology, 7938University of Toronto, Toronto, ON, Canada
| | - Michael A Seidman
- Department of Laboratory Medicine & Pathobiology, 7938University of Toronto, Toronto, ON, Canada.,Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Kate Hanneman
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network (UHN), 7938University of Toronto, Toronto, ON, Canada
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17
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du Toit R, Karamchand S, Doubell AF, Reuter H, Herbst PG. Lupus myocarditis: review of current diagnostic modalities and their application in clinical practice. Rheumatology (Oxford) 2023; 62:523-534. [PMID: 35861382 DOI: 10.1093/rheumatology/keac409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
Lupus myocarditis (LM) is a potentially fatal manifestation of SLE, occurring in 5-10% of patients. Clinical manifestations may vary from an unexplained tachycardia to fulminant congestive cardiac failure (CCF). With no single clinical or imaging modality being diagnostic, a rational and practical approach to the patient presenting with possible LM is essential. Markers of myocyte injury (including troponin I and creatine kinase) may be unelevated and do not exclude a diagnosis of LM. Findings on ECG are non-specific but remain essential to exclude other causes of CCF such as an acute coronary syndrome or conduction disorders. Echocardiographic modalities including wall motion abnormalities and speckle tracking echocardiography may demonstrate regional and/or global left ventricular dysfunction and is more sensitive than conventional echocardiography, especially early in the course of LM. Cardiac magnetic resonance imaging (CMRI) is regarded as the non-invasive diagnostic modality of choice in myocarditis. While more sensitive and specific than echocardiography, CMRI has certain limitations in the context of SLE, including technical challenges in acutely unwell and uncooperative patients, contraindications to gadolinium use in the context of renal impairment (including lupus nephritis) and limited literature regarding the application of recommended diagnostic CMRI criteria in SLE. Both echocardiography as well as CMRI may detect subclinical myocardial dysfunction and/or injury of which the clinical significance remains uncertain. Considering these challenges, a combined decision-making approach by rheumatologists and cardiologists interpreting diagnostic test results within the clinical context of the patient is essential to ensure an accurate, early diagnosis of LM.
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Affiliation(s)
| | | | | | - Helmuth Reuter
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Sharifkazemi M, Rezaian G, Lotfi M. Evaluation of myocardial performance by serial speckle tracking echocardiography in diagnosis and follow-up of a patient with eosinophilic myocarditis. Echo Res Pract 2023; 10:1. [PMID: 36698163 PMCID: PMC9878865 DOI: 10.1186/s44156-022-00013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 11/25/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Speckle tracking echocardiography (STE) has been used as an adjunct diagnostic modality in patients with eosinophilic myocarditis. Its serial dynamic nature, however, has never been reported before. CASE PRESENTATION A 17-year-old boy presented in cardiogenic shock state. His full blood count revealed an absolute eosinophilic count of 11.18 × 103/μL. An emergency 2D echocardiogram (2DE) showed global left ventricular hypokinesia with LVEF = 9.0% by Simpson's method and a large amount of pericardial effusion. STE showed a global longitudinal strain (GLS) of - 4.1%. Because of his poor clinical status and presence of marked hypereosinophilia and the possibility of eosinophilic myocarditis (EM), parenteral pulse therapy with methylprednisolone and inotropes was started with subsequent improvement within the next 48 h. Over the next few days, he had his first cardiovascular magnetic resonance imaging (CMR), which showed late gadolinium enhancement (LGE) in different cardiac regions. After two weeks of therapy, he left the hospital in a stable condition, with LVEF = 38.0%, and GLS = - 13.9%. He did well during his two months of outpatient follow-ups and was found to have an absolute eosinophil count of 0.0% on several occasions. Unfortunately, he was re-admitted because of treatment non-compliance with almost the same, albeit milder, symptoms. The WBC count was 18.1 × 103 per microliter, and the eosinophilic count was 5.04 × 103/μL (28%). Heart failure treatment and high-dose prednisolone were started. After 15 days of admission, he got better and was discharged. During both hospital admissions and several months of follow-up, he had multiple 2DEs, STE, and two CMR studies. None of his STEs were identical to the prior studies and were dynamic with frequent wax and wanes throughout the admissions and follow-ups. Thus a single admission-time STE study was not sufficient enough to properly predict the patient's outcome. Follow-up STEs showed new sites of myocardial involvement despite the absence of eosinophilia. CONCLUSION The use of STE in this patient, proved to have an added value in the evaluation and stratification of the left ventricular function in patients with EM and can be used as a diagnostic adjunct to CMR for diagnosis of EM.
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Affiliation(s)
- Mohammadbagher Sharifkazemi
- grid.412571.40000 0000 8819 4698Department of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Nemazee Square, Shiraz, 71936-13311 Iran
| | - Gholamreza Rezaian
- grid.412571.40000 0000 8819 4698Department of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Nemazee Square, Shiraz, 71936-13311 Iran
| | - Mehrzad Lotfi
- grid.412571.40000 0000 8819 4698Department of Radiology, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Chareonthaitawee P, Gutberlet M. Clinical Utilization of Multimodality Imaging for Myocarditis and Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2023; 16:e014091. [PMID: 36649452 DOI: 10.1161/circimaging.122.014091] [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: 01/19/2023]
Abstract
Myocarditis is defined as inflammation of the myocardium according to clinical, histological, biochemical, immunohistochemical, or imaging findings. Inflammation can be categorized histologically by cell type or pattern, and many causes have been implicated, including infectious, most commonly viral, systemic autoimmune diseases, vaccine-associated processes, environmental factors, toxins, and hypersensitivity to drugs. Sarcoid myocarditis is increasingly recognized as an important cause of cardiomyopathy and has important diagnostic, prognostic, and therapeutic implications in patients with systemic sarcoidosis. The clinical presentation of myocarditis may include an asymptomatic, subacute, acute, fulminant, or chronic course and may have focal or diffuse involvement of the myocardium depending on the cause and time point of the disease. For most causes of myocarditis except sarcoidosis, myocardial biopsy is the gold standard but is limited due to risk, cost, availability, and variable sensitivity. Diagnostic criteria have been established for both myocarditis and cardiac sarcoidosis and include clinical and imaging findings particularly the use of cardiac magnetic resonance and positron emission tomography. Beyond diagnosis, imaging findings may also provide prognostic value. This case-based review focuses on the current state of multimodality imaging for the diagnosis and management of myocarditis and cardiac sarcoidosis, highlighting multimodality imaging approaches with practical clinical vignettes, with a discussion of knowledge gaps and future directions.
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Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis. J Clin Med 2022; 11:jcm11226718. [PMID: 36431195 PMCID: PMC9694385 DOI: 10.3390/jcm11226718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.
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21
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Quinaglia T, Gongora C, Awadalla M, Hassan MZO, Zafar A, Drobni ZD, Mahmood SS, Zhang L, Coelho-Filho OR, Suero-Abreu GA, Rizvi MA, Sahni G, Mandawat A, Zatarain-Nicolás E, Mahmoudi M, Sullivan R, Ganatra S, Heinzerling LM, Thuny F, Ederhy S, Gilman HK, Sama S, Nikolaidou S, Mansilla AG, Calles A, Cabral M, Fernández-Avilés F, Gavira JJ, González NS, García de Yébenes Castro M, Barac A, Afilalo J, Zlotoff DA, Zubiri L, Reynolds KL, Devereux R, Hung J, Picard MH, Yang EH, Gupta D, Michel C, Lyon AR, Chen CL, Nohria A, Fradley MG, Thavendiranathan P, Neilan TG. Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis. JACC Cardiovasc Imaging 2022; 15:1883-1896. [PMID: 36357131 PMCID: PMC10334352 DOI: 10.1016/j.jcmg.2022.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/25/2022] [Accepted: 06/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS. OBJECTIVES This study aimed to detail the role of GCS and GRS in ICI myocarditis. METHODS In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death. RESULTS Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002). CONCLUSIONS GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.
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Affiliation(s)
- Thiago Quinaglia
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Carlos Gongora
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zsofia D Drobni
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Syed S Mahmood
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Otavio R Coelho-Filho
- Discipline of Cardiology, Department of Medicine, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
| | | | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania, USA
| | - Gagan Sahni
- Cardiology-Oncology Program, Mount Sinai Hospital, New York, New York, USA
| | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Ryan Sullivan
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Lucie M Heinzerling
- Department of Dermatology and Allergy, LMU Klinikum, Munich, Germany and Department of Dermatology, University Hospital Erlangen, Germany
| | - Franck Thuny
- Mediterranean University Center of Cardio-Oncology, Aix-Marseille University, North Hospital, Marseille, France
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires Est Parisien, Paris, France
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Supraja Sama
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sofia Nikolaidou
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana González Mansilla
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Antonio Calles
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Marcella Cabral
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Juan José Gavira
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | - Nahikari Salterain González
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | | | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jonathan Afilalo
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richard Devereux
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Dipti Gupta
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Caroline Michel
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, UK
| | - Carol L Chen
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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22
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Maharlou M, Kaviani R, Rezaeian N, Amin A, Omidvar R, Farrashi M. Right ventricular peak systolic free wall longitudinal strain as a practical tool to detect right ventricular dysfunction in acute myocarditis. Echocardiography 2022; 39:1291-1298. [PMID: 36126335 DOI: 10.1111/echo.15449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/21/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Acute myocarditis is one of the etiologies of acute heart failure, chronic dilated cardiomyopathy, and cardiac mortality. The extent of right ventricular (RV) involvement and its impact on the course of the disease have been scarcely studied. This study aimed to evaluate both the prevalence of RV dysfunction in acute myocarditis and echocardiographic measures as a diagnostic tool for RV dysfunction compared with cardiac magnetic resonance imaging (CMR) findings. METHODS This retrospective study enrolled patients with a definite or probable acute myocarditis diagnosis based on the Lake Louise criteria in CMR and evaluated the diagnostic accuracy of echocardiographic measures in predicting RV dysfunction in CMR. RESULTS The study population consisted of 71 patients, including 54 men (76%), at a median (Q1-Q3) age of 33 (26-46) years. CMR detected RV dysfunction in 53.5% of the patients. The RV free wall peak systolic longitudinal strain showed the highest correlation (r = -.786, p < .001) and area under the curve (.919) with the RV ejection fraction in CMR, followed by the RV global peak systolic longitudinal strain and the RV fractional area change. The RV-free wall peak systolic longitudinal strain had a sensitivity of 92% and a specificity of 73% for the diagnosis of RV dysfunction in myocarditis. A cutoff value of -17.9% was 100% specific for RV systolic dysfunction. CONCLUSIONS Echocardiography, as a readily available tool, was predictive of and had acceptable accuracy for RV dysfunction in acute myocarditis compared with CMR.
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Affiliation(s)
- Maryam Maharlou
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Raheleh Kaviani
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Rezaeian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Razieh Omidvar
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Melody Farrashi
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Mansanguan S, Charunwatthana P, Piyaphanee W, Dechkhajorn W, Poolcharoen A, Mansanguan C. Cardiovascular Manifestation of the BNT162b2 mRNA COVID-19 Vaccine in Adolescents. Trop Med Infect Dis 2022; 7:196. [PMID: 36006288 PMCID: PMC9414075 DOI: 10.3390/tropicalmed7080196] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 12/26/2022] Open
Abstract
This study focuses on cardiovascular manifestation, particularly myocarditis and pericarditis events, after BNT162b2 mRNA COVID-19 vaccine injection in Thai adolescents. This prospective cohort study enrolled students aged 13-18 years from two schools, who received the second dose of the BNT162b2 mRNA COVID-19 vaccine. Data including demographics, symptoms, vital signs, ECG, echocardiography, and cardiac enzymes were collected at baseline, Day 3, Day 7, and Day 14 (optional) using case record forms. We enrolled 314 participants; of these, 13 participants were lost to follow-up, leaving 301 participants for analysis. The most common cardiovascular signs and symptoms were tachycardia (7.64%), shortness of breath (6.64%), palpitation (4.32%), chest pain (4.32%), and hypertension (3.99%). One participant could have more than one sign and/or symptom. Seven participants (2.33%) exhibited at least one elevated cardiac biomarker or positive lab assessments. Cardiovascular manifestations were found in 29.24% of patients, ranging from tachycardia or palpitation to myopericarditis. Myopericarditis was confirmed in one patient after vaccination. Two patients had suspected pericarditis and four patients had suspected subclinical myocarditis. In conclusion, Cardiovascular manifestation in adolescents after BNT162b2 mRNA COVID-19 vaccination included tachycardia, palpitation, and myopericarditis. The clinical presentation of myopericarditis after vaccination was usually mild and temporary, with all cases fully recovering within 14 days. Hence, adolescents receiving mRNA vaccines should be monitored for cardiovascular side effects. Clinical Trial Registration: NCT05288231.
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Affiliation(s)
| | - Prakaykaew Charunwatthana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Watcharapong Piyaphanee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Wilanee Dechkhajorn
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | | | - Chayasin Mansanguan
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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24
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Goody PR, Zimmer S, Öztürk C, Zimmer A, Kreuz J, Becher MU, Isaak A, Luetkens J, Sugiura A, Jansen F, Nickenig G, Hammerstingl C, Tiyerili V. 3D-speckle-tracking echocardiography correlates with cardiovascular magnetic resonance imaging diagnosis of acute myocarditis – An observational study. IJC HEART & VASCULATURE 2022; 41:101081. [PMID: 35855974 PMCID: PMC9287637 DOI: 10.1016/j.ijcha.2022.101081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023]
Abstract
Regional changes in myocardial texture (as diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain. 3D and 2D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF and LVEDV in our patient collective. 3D-speckle-tracking echocardiography offers a promising diagnostic tool in the diagnosis of myocarditis.
Background The diagnostic importance of three-dimensional (3D) speckle-tracking strain-imaging echocardiography in patients with acute myocarditis remains unclear. The aim of this study was to test the diagnostic performance of 3D-speckle-tracking echocardiography compared to CMR (cardiovascular magnetic resonance imaging) for the diagnosis of acute myocarditis. Methods and results 45 patients with clinically suspected myocarditis were enrolled in our study (29% female, mean age: 43.9 ± 16.3 years, peak troponin I level: 1.38 ± 3.51 ng/ml). 3D full-volume echocardiographic images were obtained and offline 2D as well as 3D speckle-tracking analysis of regional and global LV deformation was performed. All patients received CMR scans and myocarditis was diagnosed in 29 subjects based on original Lake-Louise criteria. The 16 patients, in whom myocarditis was excluded by CMR, served as controls. Regional changes in myocardial texture (diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain. Interestingly, the 2D and 3D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF (as obtained by echocardiography and CMR) and LVEDV (as obtained by CMR). Conclusions In this study, we examined the use of 3D-speckle-tracking echocardiography in patients with acute myocarditis. Global longitudinal strain was significantly impaired in patients with acute myocarditis and correlated with CMR findings. Therefore, 3D echocardiography could become a useful diagnostic tool in the primary diagnosis of myocarditis.
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Affiliation(s)
- Philip Roger Goody
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Angela Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Jens Kreuz
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Marc Ulrich Becher
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Alexander Isaak
- Department of Radiology, University Hospital Bonn, Venusberg-Campus 1, 53125 Bonn, Germany
| | - Julian Luetkens
- Department of Radiology, University Hospital Bonn, Venusberg-Campus 1, 53125 Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Felix Jansen
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Christoph Hammerstingl
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Vedat Tiyerili
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Department of Internal Medicine I, St.-Johannes-Hospital Dortmund, Dortmund, Germany
- Corresponding author at: Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Venusberg-Campus 1, 53125 Bonn, Germany.
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25
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Keshavarz P, Yazdanpanah F, Emad M, Hajati A, Nejati SF, Ebrahimian Sadabad F, Azrumelashvili T, Mizandari M, Raman SS. Myocarditis Following COVID-19 Vaccination: Cardiac Imaging Findings in 118 Studies. Tomography 2022; 8:1959-1973. [PMID: 36006062 PMCID: PMC9416085 DOI: 10.3390/tomography8040164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
We reviewed the reported imaging findings of myocarditis in the literature following COVID-19 vaccination on cardiac imaging by a literature search in online databases, including Scopus, Medline (PubMed), Web of Science, Embase (Elsevier), and Google Scholar. In total, 532 cases of myocarditis after COVID-19 vaccination were reported (462, 86.8% men and 70, 13.2% women, age range 12 to 80) with the following distribution: Pfizer-BioNTech: 367 (69%), Moderna: 137 (25.8%), AstraZeneca: 12 (2.3%), Janssen/Johnson & Johnson: 6 (1.1%), COVAXIN: 1 (0.1%), and unknown mRNA vaccine: 9 (1.7%). The distribution of patients receiving vaccine dosage was investigated. On cardiac MR Imaging, late intravenous gadolinium enhancement (LGE) was observed mainly in the epicardial/subepicardial segments (90.8%, 318 of 350 enhancing segments), with the dominance of inferolateral segment and inferior walls. Pericardial effusion was reported in 13.1% of cases. The vast majority of patients (94%, 500 of 532) were discharged from the hospital except for 4 (0.7%) cases. Post-COVID-19 myocarditis was most commonly reported in symptomatic men after the second or third dose, with CMRI findings including LGE in 90.8% of inferior and inferolateral epicardial/subepicardial segments. Most cases were self-limited.
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Affiliation(s)
- Pedram Keshavarz
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (P.K.); (S.S.R.)
- School of Science and Technology, The University of Georgia, Tbilisi 0171, Georgia
| | - Fereshteh Yazdanpanah
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tabriz 5166, Iran;
| | - Maryam Emad
- Taba Medical Imaging Center, Shiraz 71347-53151, Iran; (M.E.); (A.H.); (S.F.N.); (F.E.S.)
| | - Azadeh Hajati
- Taba Medical Imaging Center, Shiraz 71347-53151, Iran; (M.E.); (A.H.); (S.F.N.); (F.E.S.)
| | - Seyed Faraz Nejati
- Taba Medical Imaging Center, Shiraz 71347-53151, Iran; (M.E.); (A.H.); (S.F.N.); (F.E.S.)
| | | | - Tamta Azrumelashvili
- Department of Diagnostic & Interventional Radiology, New Hospitals Ltd., Tbilisi 0114, Georgia;
| | - Malkhaz Mizandari
- Department of Diagnostic & Interventional Radiology, New Hospitals Ltd., Tbilisi 0114, Georgia;
| | - Steven S. Raman
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (P.K.); (S.S.R.)
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Sozzi FB, Gherbesi E, Faggiano A, Gnan E, Maruccio A, Schiavone M, Iacuzio L, Carugo S. Viral Myocarditis: Classification, Diagnosis, and Clinical Implications. Front Cardiovasc Med 2022; 9:908663. [PMID: 35795363 PMCID: PMC9250986 DOI: 10.3389/fcvm.2022.908663] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Myocarditis is an inflammatory disease of the myocardium with focal or diffuse involvement. Viral infections are the most common cause of myocarditis, especially in Western countries. A recent viral illness with gastroenteric or upper respiratory symptoms often precedes myocarditis. The absence of specific pathognomonic features in conjunction with the wide spectrum of clinical manifestations that range from subclinical cases to sudden cardiac death (SCD) makes myocarditis diagnosis particularly challenging. Moreover, myocarditis might represent a cause of initially unexplained dilated cardiomyopathy (DCM) and heart failure (HF), especially among children and young adults. Cardiac magnetic resonance imaging (CMR) is crucial for myocarditis diagnosis, because of its ability to detect interstitial edema during acute inflammation. Assessment of subepicardial or mid-myocardial fibrosis by late gadolinium enhancement (LGE) is typical for myocarditis. Cardiac arrhythmias are frequent events that may arise especially in more severe myocarditis cases. The most common form of arrhythmia is atrial fibrillation, followed by ventricular tachycardia. Documented arrhythmias have been reported more commonly with HIV myocarditis than other more common infections such as Adenovirus, Parvovirus B19, human Herpes virus 6, and Enterovirus. The mechanisms of arrhythmogenesis in myocardial inflammation are not fully understood; in the acute phase, the spectrum of arrhythmogenesis ranges from a direct effect on cardiomyocytes that leads to electrical instability and ion channel impairment to ischemia from coronary macro- or microvascular disease. In chronic myocarditis, instead, myocardial replacement with fibrosis promotes scar-mediated re-entrant ventricular arrhythmias. Observational data suggested the important role of CMR, with LGE being the strongest independent predictor of SCD, cardiac, and all-cause mortality. In acute myocarditis, the most common localization of subepicardial LGE dwells in the lateral wall. Patients with myocarditis that develop HF and arrhythmias usually show a larger LGE distribution involving several myocardial segments. Moreover, a mid-layer LGE in the interventricular septum is more frequent in acute myocarditis than in acute coronary syndromes cases. The risk of SCD in patients with wide areas of LGE is significant, and a shared decision-making approach is warranted. Nevertheless, there is no formal consensus about the extension of LGE to justify implantable cardioverter defibrillator (ICD) implantation in primary prevention.
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Affiliation(s)
- Fabiola B. Sozzi
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Elisa Gherbesi
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Andrea Faggiano
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Eleonora Gnan
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Alessio Maruccio
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Marco Schiavone
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | | | - Stefano Carugo
- Cardiology Unit, Internal Medicine Department, Fondazione Ospedale Maggiore Policlinico IRCCS Cà Granda, University of Milan, Milan, Italy
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Zayour M, Al Ashkar R, Karaki M, Chammas E, Shatila W. Focal Myocarditis As the First Sign in the Presentation of a COVID-19 Infection: A Case Report. Cureus 2022; 14:e26358. [PMID: 35903566 PMCID: PMC9326958 DOI: 10.7759/cureus.26358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Patients with COVID-19 typically present with symptoms and signs related to respiratory tract infection. However, a broad spectrum of cardiac manifestations including myocarditis has been reported as complications of this virus. Nevertheless, focal myocarditis as the first clinical manifestation of COVID-19 infection has not been reported before. Thus, we herein present the case of a 56-year-old male patient previously healthy and presented to the emergency department with chest pain. The clinical picture was compatible with inferior ST-elevation myocardial infarction (STEMI). Initial COVID-19 polymerase chain reaction (PCR) was negative, as well for its classic symptoms. Thereafter, further investigations suggested the diagnosis of focal myocarditis. Later on, the patient started to have a fever and repeated COVID-19 PCR that returned positive.
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Affiliation(s)
| | - Rana Al Ashkar
- Internal Medicine, Faculty of Medicine, Lebanese University, Beirut, LBN
| | - Mahmoud Karaki
- Diabetes and Endocrinology, University of Balamand, Beirut, LBN
| | - Elie Chammas
- Cardiology, Clemenceau Medical Center, Beirut, LBN
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Marschner CA, Shaw KE, Tijmes FS, Fronza M, Khullar S, Seidman MA, Thavendiranathan P, Udell JA, Wald RM, Hanneman K. Myocarditis Following COVID-19 Vaccination. Cardiol Clin 2022; 40:375-388. [PMID: 35851461 PMCID: PMC9072816 DOI: 10.1016/j.ccl.2022.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Cau R, Bassareo P, Deidda M, Caredda G, Suri JS, Pontone G, Saba L. Could CMR Tissue-Tracking and Parametric Mapping Distinguish Between Takotsubo Syndrome and Acute Myocarditis? A Pilot Study. Acad Radiol 2022; 29 Suppl 4:S33-S39. [PMID: 33487539 DOI: 10.1016/j.acra.2021.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/03/2021] [Accepted: 01/07/2021] [Indexed: 02/09/2023]
Abstract
RATIONALE AND OBJECTIVE Takotsubo syndrome (TS) is a transient and often misdiagnosed form of left ventricular dysfunction. Acute myocarditis (AM) is usually included in TS differential diagnosis. The aim of this study is to assess the role of cardiac magnetic resonance imaging coupled with tissue-tracking technique (CMR-TT) and parametric mappings analysis in discriminating between TS and AM. MATERIALS AND METHODS We retrospectively enrolled three groups: patients with TS (n = 12), patients with AM (n = 14), and 10 healthy controls. All the patients had a comprehensive CMR examination, including the assessment of global and segmental longitudinal strain, circumferential strain, radial strain (RS), and parametric mapping. RESULTS The analysis of variance was used to compare the different groups. In TS patients, basal RS, global T1 mapping, global T2 mapping, mid T2 mapping, apical T1 and T2 mapping were statistically significantly different compared with the other groups. MANCOVA analysis confirmed that the association between myocardial strain data and parametric mapping was independent on age and sex. Apical T1 and T2 mapping proved to have a good performance in differentiating TS from AM (area under the curves of 0.908 and 0.879, respectively). CONCLUSION Basal RS and apical tissue mapping analysis are the most advanced CMR-derived parameters in making a differential diagnosis between TS and AM.
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The Diagnostic Role of Echocardiographic Strain Analysis in Patients Presenting with Chest Pain and Elevated Troponin: A Multicenter Study. J Am Soc Echocardiogr 2022; 35:857-867. [PMID: 35301094 DOI: 10.1016/j.echo.2022.03.009] [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] [Received: 03/30/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Myocarditis presenting as acute chest pain with elevated troponins without significant cardiac compromise is rare in previously healthy children, often referred to as myopericarditis. Diagnosis is challenging as conventional echocardiographic measures of systolic function can be normal. This study aimed to demonstrate the diagnostic utility of strain imaging in this scenario. METHODS This is a multi-center retrospective study including patients presenting with chest pain and elevated troponin from 10 institutions who underwent cardiac MRI (CMR) and transthoracic echocardiogram (echo) within 30 days of each other (group 1). Findings were compared to 19 controls (group 2). Clinical data, conventional echo and CMR data were collected. Echo-derived strain was measured at the core lab. Group 1 was divided into subgroups as CMR myocarditis positive (group 1a) or negative (group 1b) based on established criteria. RESULTS Group 1 included 108 subjects (88 in group 1a, 20 in group 1b). While all groups had normal mean fractional shortening (FS) and mean left ventricular ejection fraction (LVEF), group 1 had significantly lower EF (56.8+/-7.0) compared to group 2 ( 62.3+/- 4.9, P<0.005) and FS (31.2+/- 4.9) compared to group 2 (34.1+/-3.5, p<0.05). Additionally, peak global longitudinal strain (GLS%) was markedly abnormal in group 1 (-13.9+/-3.4 ) compared to group 2 (-19.8+/-2.1 , P<0.001). In subgroup analysis, GLS% was markedly abnormal in group 1a (-13.2 ± 3.0%) compared to group 1b (-17.3 ± 2.6% and p<0.001). Fifty-four subjects had follow up echocardiograms (46 in group 1a, 8 in group 1b) with mean follow-up time of 10 months (SD=11 months). At follow up, while EF and FS returned to normal in all patients, abnormalities in strain persisted in group 1, with 22% of them still having abnormal GLS. Moreover, mean GLS was more abnormal in group 1a (-16.1 +/- 2.6) compared to group 1b (-17.4+/- 1.2, p<0.05). CONCLUSIONS Our study demonstrates that echo GLS% is significantly worse in subjects with myopericarditis presenting with chest pain and elevated troponins compared to controls even when conventional measures of systolic function are largely normal and that these abnormalities persisted overtime.
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A Review of the Role of Imaging Modalities in the Evaluation of Viral Myocarditis with a Special Focus on COVID-19-Related Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12020549. [PMID: 35204637 PMCID: PMC8870822 DOI: 10.3390/diagnostics12020549] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 12/12/2022] Open
Abstract
Viral myocarditis is inflammation of the myocardium secondary to viral infection. The clinical presentation of viral myocarditis is very heterogeneous and can range from nonspecific symptoms of malaise and fatigue in subclinical disease to a more florid presentation, such as acute cardiogenic shock and sudden cardiac death in severe cases. The accurate and prompt diagnosis of viral myocarditis is very challenging. Endomyocardial biopsy is considered to be the gold standard test to confirm viral myocarditis; however, it is an invasive procedure, and the sensitivity is low when myocardial involvement is focal. Cardiac imaging hence plays an essential role in the noninvasive evaluation of viral myocarditis. The current coronavirus disease 2019 (COVID-19) pandemic has generated considerable interest in the use of imaging in the early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related myocarditis. This article reviews the role of various cardiac imaging modalities used in the diagnosis and assessment of viral myocarditis, including COVID-19-related myocarditis.
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Nunn S, Kersten J, Tadic M, Wolf A, Gonska B, Hüll E, Dietenberger H, Rottbauer W, Buckert D. Case Report: Myocarditis After COVID-19 Vaccination - Case Series and Literature Review. Front Med (Lausanne) 2022; 9:836620. [PMID: 35237634 PMCID: PMC8882906 DOI: 10.3389/fmed.2022.836620] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/20/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The ongoing COVID-19 pandemic demands a series of measures and, above all, the vaccination of a substantial proportion of the population. Acute myocarditis is a rare complication of the widely used mRNA-based vaccines. CASE PRESENTATION We present a case series of four patients (three men and one woman, 16 to 47 years old) with acute pericarditis/myocarditis 3 to 17 days after mRNA vaccination. They presented with chest pain, fever, and flu-like symptoms. Diagnosis was made based on the synopsis of clinical presentation, elevated levels of troponin T and NT-proBNP, impaired systolic function on echocardiography, and findings in non-invasive tissue characterization by cardiovascular magnetic resonance imaging. Two patients also underwent endomyocardial biopsies. As none of the patients showed signs of cardiogenic shock, they were discharged from ward care only a few days after their initial presentations. CONCLUSIONS Our data are consistent with other case reports of myocarditis early after mRNA vaccination and demonstrate the need for multimodal diagnostics. In view of its rarity and mild course, the risk-benefit ratio of vaccination remains positive compared to potential SARS-CoV-2 infection.
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Affiliation(s)
- Samuel Nunn
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | - Johannes Kersten
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | - Marijana Tadic
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | - Alexander Wolf
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | - Birgid Gonska
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | - Elina Hüll
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
| | | | | | - Dominik Buckert
- Department for Internal Medicine II, University of Ulm, Ulm, Germany
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Farhat N, Bouhabib M, Joye R, Vallée JP, Beghetti M. Contribution of imaging modalities to eosinophilic myocarditis diagnosis: a case report. Eur Heart J Case Rep 2022; 6:ytac058. [PMID: 35295721 PMCID: PMC8922693 DOI: 10.1093/ehjcr/ytac058] [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: 02/10/2021] [Revised: 04/28/2021] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
Background Eosinophilic myocarditis (EM) is a relatively rare form of myocarditis that could progress to restrictive cardiomyopathy and might be fatal if left untreated. Although myocardial biopsy is considered to be the gold standard for the diagnosis of myocarditis, its use in paediatrics remains controversial and not easily applicable in routine practice. Case summary A 10-year-old girl with no prior medical history presented to the emergency department for fever, odynophagia, and gastrointestinal symptoms despite 48 h of antibiotics (Cefaclor). Physical examination revealed diffuse petechiae and abdominal tenderness but was otherwise unremarkable. Her vital signs were normal. She was found to have hypereosinophilia and increased cardiac markers on laboratory testing. Echocardiography showed diffuse left ventricular (LV) myocardial infiltrates, moderate LV dilatation, and mild systolic dysfunction. Bone marrow biopsy confirmed B cell acute lymphoblastic leukaemia. The diagnosis of EM was made. High doses of steroids and chemotherapy were initiated. Cardiac magnetic resonance imaging (MRI) identified eosinophilic infiltrates and sub-endocardial enhancement strongly suggestive of EM. Left ventricular function was slightly decreased. Intra-ventricular micro-thrombi were suspected, and warfarin was started. The outcome was favourable. Leucocyte and eosinophil counts were normalized within a month. At 6 months, cardiac MRI demonstrated a significant decrease in eosinophilic infiltration and micro-thrombi, normalization of LV function, and of sub-endocardial enhancement. Discussion This case demonstrates that non-invasive multi-modality imaging along with typical laboratory and clinical findings allow for appropriate diagnosis of EM while avoiding biopsy. It also highlights that an early diagnosis, timely treatment, and rigorous follow-up improve disease progression and outcome.
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Affiliation(s)
- Nesrine Farhat
- Pediatric Cardiology Unit, Pediatric Department, University Hospital Liège (CHU), Rue de Gaillarmont 600, 4030 Liège, Belgium
| | - Maya Bouhabib
- Pediatric Cardiology Unit and Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique (CHUV and HUG), Pediatric Department, University of Geneva and Lausanne, Geneva, Switzerland
| | - Raphael Joye
- Pediatric Cardiology Unit and Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique (CHUV and HUG), Pediatric Department, University of Geneva and Lausanne, Geneva, Switzerland
| | - Jean-Paul Vallée
- Cardiovascular Radiology Unit, Radiology Department, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique (CHUV and HUG), Pediatric Department, University of Geneva and Lausanne, Geneva, Switzerland
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34
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Symanski JD, Tso JV, Phelan DM, Kim JH. Myocarditis in the Athlete: a focus on COVID-19 sequelae. Clin Sports Med 2022; 41:455-472. [PMID: 35710272 PMCID: PMC8849834 DOI: 10.1016/j.csm.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gupta S, Gupta M, Kashyap JR, Arora SK. Early cardiovascular involvement in dengue fever: A prospective study with two-dimensional speckle tracking echocardiography. Trop Doct 2022; 52:285-292. [DOI: 10.1177/00494755221076686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiac abnormalities in dengue infection have been conventionally identified by clinical manifestations. The primary objective of our prospective observational study was to assess true cardiovascular involvement and early myocarditis in 150 hospitalised, confirmed cases of dengue fever, through myocardial strain detection using two-dimensional speckle tracking echocardiography. Myocarditis was defined on the basis of European Society of Cardiology (ESC) 2013 criteria. Cardiac biomarkers, namely, creatine phosphokinase myocardial band was elevated in 28.6% and Troponin-T in 23.3% patients. Electrocardiography was abnormal in 64.6% while 6% patients had two-dimensional structural echocardiographic abnormalities. Myocardial dysfunction was suspected in 27.3% based on ESC criteria and strain analysis. The severe dengue group had lower longitudinal strain [−16.4 (6.3)] and circumferential strain [−15.7 (6.7)]. Two-dimensional speckle tracking echocardiography was found to be useful in improving the understanding of early myocardial mechanics in dengue fever.
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Affiliation(s)
- Samiksha Gupta
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Monica Gupta
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Jeet Ram Kashyap
- Department of Cardiology, Government Medical College and Hospital, Chandigarh, India
| | - Suraj Kumar Arora
- Department of Cardiology, All India Institute Medical Sciences, Bathinda, India
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Tymińska A, Ozierański K, Skwarek A, Kapłon-Cieślicka A, Baritussio A, Grabowski M, Marcolongo R, Caforio ALP. Personalized Management of Myocarditis and Inflammatory Cardiomyopathy in Clinical Practice. J Pers Med 2022; 12:jpm12020183. [PMID: 35207671 PMCID: PMC8874629 DOI: 10.3390/jpm12020183] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/01/2023] Open
Abstract
Myocarditis is an inflammatory heart disease induced by infectious and non-infectious causes frequently triggering immune-mediated pathologic mechanisms leading to myocardial damage and dysfunction. In approximately half of the patients, acute myocarditis resolves spontaneously while in the remaining cases, it may evolve into serious complications including inflammatory cardiomyopathy, arrhythmias, death, or heart transplantation. Due to the large variability in clinical presentation, unpredictable course of the disease, and lack of established causative treatment, myocarditis represents a challenging diagnosis in modern cardiology. Moreover, an increase in the incidence of myocarditis and inflammatory cardiomyopathy has been observed in recent years. However, there is a growing potential of available non-invasive diagnostic methods (biomarkers, serum anti-heart autoantibodies (AHA), microRNAs, speckle tracking echocardiography, cardiac magnetic resonance T1 and T2 tissue mapping, positron emission tomography), which may refine the diagnostic workup and/or noninvasive follow-up. Personalized management should include the use of endomyocardial biopsy and AHA, which may allow the etiopathogenetic subsets of myocarditis (infectious, non-infectious, and/or immune-mediated) to be distinguished and implementation of disease-specific therapies. In this review, we summarize current knowledge on myocarditis and inflammatory cardiomyopathy, and outline some practical diagnostic, therapeutic, and follow-up algorithms to facilitate comprehensive individualized management of these patients.
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Affiliation(s)
- Agata Tymińska
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland; (A.T.); (A.S.); (A.K.-C.); (M.G.)
| | - Krzysztof Ozierański
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland; (A.T.); (A.S.); (A.K.-C.); (M.G.)
- Correspondence: ; Tel.: +48-22-599-29-58; Fax: +48-22-599-19-57
| | - Aleksandra Skwarek
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland; (A.T.); (A.S.); (A.K.-C.); (M.G.)
| | - Agnieszka Kapłon-Cieślicka
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland; (A.T.); (A.S.); (A.K.-C.); (M.G.)
| | - Anna Baritussio
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 2-35128 Padova, Italy; (A.B.); (R.M.); (A.L.C.)
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland; (A.T.); (A.S.); (A.K.-C.); (M.G.)
| | - Renzo Marcolongo
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 2-35128 Padova, Italy; (A.B.); (R.M.); (A.L.C.)
| | - Alida LP Caforio
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 2-35128 Padova, Italy; (A.B.); (R.M.); (A.L.C.)
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Sexson Tejtel SK, Munoz FM, Al-Ammouri I, Savorgnan F, Guggilla RK, Khuri-Bulos N, Phillips L, Engler RJM. Myocarditis and pericarditis: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2022; 40:1499-1511. [PMID: 35105494 DOI: 10.1016/j.vaccine.2021.11.074] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 02/07/2023]
Abstract
Myocarditis and/or pericarditis (also known as myopericarditis) are inflammatory diseases involving the myocardium (with non-ischemic myocyte necrosis) and/or the pericardial sac. Myocarditis/pericarditis (MPC) may present with variable clinical signs, symptoms, etiologies and outcomes, including acute heart failure, sudden death, and chronic dilated cardiomyopathy. Possible undiagnosed and/or subclinical acute myocarditis, with undefined potential for delayed manifestations, presents further challenges for diagnosing an acute disease and may go undetected in the setting of infection as well as adverse drug/vaccine reactions. The most common causes of MPC are viral, with non-infectious, drug/vaccine associated hypersensitivity and/or autoimmune causes being less well defined and with potentially different inflammatory mechanisms and treatment responses. Potential cardiac adverse events following immunization (AEFIs) encompass a larger scope of diagnoses such as triggering or exacerbating ischemic cardiac events, cardiomyopathy with potential heart failure, arrhythmias and sudden death. The current published experience does not support a potential causal association with vaccines based on epidemiologic evidence of relative risk increases compared with background unvaccinated incidence. The only evidence supporting a possible causal association of MPC with a vaccine comes from case reports. Hypersensitivity MPC as a drug/vaccine induced cardiac adverse event has long been a concern for post-licensure safety surveillance, as well as safety data submission for licensure. Other cardiac adverse events, such as dilated cardiomyopathy, were also defined in the CDC definitions for adverse events after smallpox vaccination in 2006. In addition, several groups have attempted to develop and improve the definition and adjudication of post-vaccination cardiovascular events. We developed the current case definitions for myocarditis and pericarditis as an AEFI building on experience and lessons learnt, as well as a comprehensive literature review. Considerations of other etiologies and causal relationships are outside the scope of this document.
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Affiliation(s)
| | - Flor M Munoz
- Departments of Pediatrics, Section of Infectious Diseases, and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
| | - Iyad Al-Ammouri
- Pediatric Cardiology, The University of Jordan. Amman, Jordan
| | - Fabio Savorgnan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rama K Guggilla
- Department of Population Medicine and Lifestyle Diseases Prevention, Faculty of Medicine with the Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Poland
| | - Najwa Khuri-Bulos
- Pediatric Infectious Diseases, Vaccines, The University of Jordan, Amman, Jordan
| | - Lee Phillips
- Pharmaco-epidemiology, Cardiovascular Drug Safety, USA
| | - Renata J M Engler
- Allergy-Immunology-Immunizations, Department of Medicine, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, and Immunization Healthcare Division, Defense Health Agency, Bethesda, MD, USA
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38
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Novo G, Di Lisi D, La Franca E, Carmina MG, Trovato RL, Romano G, Novo S, Clemenza F, Di Bella G, Bellavia D. Usefulness of longitudinal systolic strain and delayed enhancement cardiac magnetic resonance in depicting risk of supraventricular arrythmias in patients with acute myocarditis and preserved left ventricular function. Echocardiography 2022; 39:294-301. [DOI: 10.1111/echo.15306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/07/2021] [Accepted: 01/01/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Giuseppina Novo
- Department of Health Promotion Mother and Child Care, Internal Medicine and Medical Specialties Cardiology Unit University Hospital P. Giaccone University of Palermo Palermo Italy
| | - Daniela Di Lisi
- Department of Health Promotion Mother and Child Care, Internal Medicine and Medical Specialties Cardiology Unit University Hospital P. Giaccone University of Palermo Palermo Italy
| | - Eluisa La Franca
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS ⁻ ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) Palermo Italy
| | | | - Rosaria Linda Trovato
- Department of Health Promotion Mother and Child Care, Internal Medicine and Medical Specialties Cardiology Unit University Hospital P. Giaccone University of Palermo Palermo Italy
| | - Giuseppe Romano
- Division of Cardiology Department of Internal Medicine Hospital V. Cervello Palermo Italy
| | - Salvatore Novo
- Department of Health Promotion Mother and Child Care, Internal Medicine and Medical Specialties Cardiology Unit University Hospital P. Giaccone University of Palermo Palermo Italy
| | - Francesco Clemenza
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS ⁻ ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) Palermo Italy
| | - Gianluca Di Bella
- Clinical and Experimental Department of Medicine and Pharmacology Faculty of Medicine University of Messina Messina Italy
| | - Diego Bellavia
- Division of Cardiology Department of Internal Medicine Hospital V. Cervello Palermo Italy
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Røsner A, Alessandrini M, Kjønås D, Mirea O, Queirós S, D Hooge J. Quality Assurance of Segmental Strain Values Provided by Commercial 2-D Speckle Tracking Echocardiography Using in Silico Models: A Report from the EACVI-ASE Strain Standardization Task Force. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3079-3089. [PMID: 34392996 DOI: 10.1016/j.ultrasmedbio.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 06/13/2023]
Abstract
The aim of this study was to determine the accuracy and reproducibility of vendor-specific regional strain values by echocardiography using in silico data. Synthetic 2-D ultrasound gray-scale images of the left ventricle (LV) were generated with knowledge of the longitudinal segmental strain values from the underlying electromechanical LV model. Four of five models mimicked transmural infarctions with systolic segmental stretching in different vascular areas. Cine loops in the three apical views were synthetically generated at four noise levels. All in silico images were repeatedly analyzed by a single investigator and some by another investigator. The absolute errors varied significantly between vendors from 3.3 ± 3.1% to 11.2 ± 5.9%. The area under the curve for the identification of segmental stretching ranged from 0.80 (confidence interval: 0.77-0.83) to 0.96 (0.95-0.98). The levels of agreement for intra-investigator variability varied between -3.0% to 2.9% and -5.2% to 4.8%, and for inter-investigator variability, between -3.6% to 3.5% and -14.5% to 8.5%. Segmental strain analysis allows the identification of areas with segmental stretching with good accuracy. However, single segmental peak-strain values are not accurate and should be interpreted with caution. Nevertheless, our results indicate the usefulness of semiquantitative strain assessment for the detection of regional dysfunction.
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Affiliation(s)
- Assami Røsner
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | | | - Didrik Kjønås
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway
| | - Oana Mirea
- Department of Cardiovascular Sciences, KU Leuven, Belgium; Department of Cardiology, University of Medicine and Pharmacy, Craiova, Romania
| | - Sandro Queirós
- Department of Cardiovascular Sciences, KU Leuven, Belgium; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jan D Hooge
- Department of Cardiovascular Sciences, KU Leuven, Belgium.
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Abstract
Purpose of Review The COVID-19 pandemic has had a profound impact on athletics, and the question of safely resuming competitive sports at all levels has been a source of significant debate. Concerns regarding myocarditis and the risk of arrhythmias and sudden death in athletes have prompted heightened attention to the role of cardiovascular screening. In this review, we aim to comprehensively outline the cardiovascular manifestations associated with COVID-19 infection, to discuss screening, diagnosis, and treatment strategies, and to evaluate the current literature on the risk to athletes and recommendations regarding return-to-play. Recent Findings COVID-19 is known to cause myocarditis, with presentations ranging from subclinical current or prior infection detected on cardiac MRI imaging, to fulminant heart failure and shock. While initial data early in the pandemic suggested that the risk of myocarditis could be significant even in patients with nonsevere COVID-19 infection, recent studies suggest a very low prevalence of clinically significant disease in young athletes. Summary While COVID-19 can have significant cardiovascular manifestations, recent data demonstrate that a screening approach guided by severity of COVID-19 infection and cardiovascular symptoms allows the majority of athletes to safely return to play in a timely manner. We must continue to tailor our approach to screening athletes as knowledge grows, and further research on the longitudinal cardiovascular effects of COVID-19 is needed.
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Patel YR, Louis DW, Atalay M, Agarwal S, Shah NR. Cardiovascular magnetic resonance findings in young adult patients with acute myocarditis following mRNA COVID-19 vaccination: a case series. J Cardiovasc Magn Reson 2021; 23:101. [PMID: 34496880 PMCID: PMC8425992 DOI: 10.1186/s12968-021-00795-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/14/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Messenger RNA (mRNA) coronavirus disease of 2019 (COVID-19) vaccine are known to cause minor side effects at the injection site and mild global systemic symptoms in first 24-48 h. Recently published case series have reported a possible association between acute myocarditis and COVID-19 vaccination, predominantly in young males. METHODS We report a case series of 5 young male patients with cardiovascular magnetic resonance (CMR)-confirmed acute myocarditis within 72 h after receiving a dose of an mRNA-based COVID-19 vaccine. RESULTS Our case series suggests that myocarditis in this setting is characterized by myocardial edema and late gadolinium enhancement in the lateral wall of the left ventricular (LV) myocardium, reduced global LV longitudinal strain, and preserved LV ejection fraction. All patients in our series remained clinically stable during a relatively short inpatient hospital stay. CONCLUSIONS In conjunction with other recently published case series and national vaccine safety surveillance data, this case series suggests a possible association between acute myocarditis and COVID-19 vaccination in young males and highlights a potential pattern in accompanying CMR abnormalities.
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Affiliation(s)
- Yash R Patel
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Lifespan Cardiovascular Institute, Warren Alpert Medical School at Brown University, 950 Warren Avenue, Suite 201, East Providence, RI, 02914, USA.
| | - David W Louis
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael Atalay
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Saurabh Agarwal
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Nishant R Shah
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Fung RCM, Hon KL, Leung AKC. Acute Myocarditis in Children: An Overview of Treatment and Recent Patents. ACTA ACUST UNITED AC 2021; 14:106-116. [PMID: 32013855 DOI: 10.2174/1872213x14666200204103714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis. METHODS Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine. RESULTS Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking. CONCLUSION This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.
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Affiliation(s)
- Ronald C M Fung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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Usefulness of Left Ventricular Myocardial Deformation in Children Hospitalized for Acute Myocarditis who Develop Arrhythmias. Am J Cardiol 2021; 152:113-119. [PMID: 34148631 PMCID: PMC10103582 DOI: 10.1016/j.amjcard.2021.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022]
Abstract
Cardiac arrhythmias occur in 3-40% of patients with acute myocarditis and cause significant morbidity and mortality. Myocardial injury also results in abnormal myocardial deformation. The relationship between left ventricular (LV) deformation, measured by two-dimensional speckle tracking echocardiography (2D-STE), and arrhythmia in pediatric myocarditis is unknown. We evaluated the association between 2D-STE and arrhythmias in children hospitalized with acute myocarditis. We reviewed patients ≤ 18 years hospitalized for acute myocarditis from 2008 to 2018. Arrhythmias were defined as 1) non-sustained or sustained ventricular tachycardia or ventricular fibrillation, 2) sustained supraventricular tachycardia (SVT), 3) high-grade or complete heart block, and 4) any arrhythmia treated with an antiarrhythmic medication. Systolic LV strain values (including LV global longitudinal strain (GLS), global circumferential strain (GCS), and six segments of LV regional long axis strain) were obtained from initial echocardiograms during hospitalization. Of 66 patients hospitalized, 23 (35%) had arrhythmias. SVT was the predominant arrhythmia (74%). Global and regional strain indices were reduced in the arrhythmia group: LV GLS [-8.9 (IQR -13.6, -6.1) vs. -13.7 (IQR -16.9, -9.7), p = 0.038]; basal inferior/septal [-10.7 (IQR -15.5, -7.8) vs. -16.4 (IQR -18, -11.8), p = 0.009]; basal anterior/lateral [-7.1 (IQR -12.8, -4.7) vs. -9.4 (IQR -16.7, -7.4), p = 0.025]; and mid inferior/septal segments [-9 (IQR -13, -7.7) vs. -14.1 (IQR -22.5, -10.7), p = 0.007]. After controlling for age, reductions in GLS and segmental strain in the two basal and two mid-segments were associated with increased arrhythmia occurrence (p <0.05). Our findings suggest that echocardiographic LV deformation by 2D-STE may be useful in identifying pediatric patients with acute myocarditis at risk for arrhythmias.
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Sperlongano S, D'Amato A, Tagliamonte E, Russo V, Desiderio A, Ilardi F, Muscogiuri G, Esposito G, Pontone G, Esposito G, D'Andrea A. Acute myocarditis: prognostic role of speckle tracking echocardiography and comparison with cardiac magnetic resonance features. Heart Vessels 2021; 37:121-131. [PMID: 34175961 DOI: 10.1007/s00380-021-01893-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/18/2021] [Indexed: 11/28/2022]
Abstract
To evaluate longitudinal systolic function in patients with myocarditis, its correlation with cardiac magnetic resonance (CMR) features, and its predictive value in functional recovery and arrhythmias onset during follow-up (FU) on optimized medical therapy (OMT). Patients with acute myocarditis, confirmed through CMR criteria, and age- and sex-matched healthy controls were enrolled. Two-dimensional (2D) transthoracic echocardiography, including speckle tracking analysis, was performed at admission and after 6 months of FU. Patients of myocarditis group also underwent 24 h ECG Holter monitoring during FU. 115 patients with myocarditis (mean age 41 ± 17, 70% males) and 70 healthy subjects were enrolled. Global longitudinal strain (GLS) and sub-epicardial strain were markedly lower in the myocarditis group than in controls (mean GLS%: - 14.1 ± 5.1 vs - 23.1 ± 3.6, p < 0.001). A strong positive correlation between total scar burden (TSB) on CMR and baseline LV GLS was found (r = 0.67, p < 0.0001). GLS improved after 6 months of FU in myocarditis on OMT (mean GLS%: - 14.1 ± 5.1 vs - 16.5 ± 4.8, p < 0.01). By bivariate correlation analysis, baseline LVEF, GLS, and TSB were all associated with LVEF at 6 months of FU. Moreover, by multivariable linear regression analysis, these parameters confirmed to be independent predictors of functional recovery at 6 months (LVEF β 0.38, p < 0.01; GLS β - 0.35, p < 0.01; total scar burden β - 0.52, p < 0.0001). Segmental peak systolic strain was significantly different between segments with and without late gadolinium enhancement on CMR (- 13.2 ± 3.1% vs - 18.1 ± 3.5%, p < 0.001). A segmental strain of - 12% identified scar with a sensitivity of 79% and a specificity of 84% (AUC = 0.91; 95% CI 0.73-0.97; p < 0.001). In addition, baseline LV GLS in myocarditis resulted predictive of non-sustained ventricular tachycardias (cut-off value > - 12%; sensitivity84%; specificity74.4%; AUC = 0.75). Parameters of myocardial longitudinal deformation are importantly associated with the presence of a scar on CMR and are predictors of functional outcome and ventricular arrhythmias in patients with acute myocarditis. Their assessment during ultrasound examination should be considered to get more information about the prognosis and risk stratification of this subset of patients.
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Affiliation(s)
- Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Andrea D'Amato
- Division of Cardiology, Anna Rizzoli di Lacco Ameno Hospital, Naples, Italy.,Division of Cardiology, Umberto I Hospital, Nocera Inferiore, SA, Italy
| | | | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Alfonso Desiderio
- Division of Cardiology, Umberto I Hospital, Nocera Inferiore, SA, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Giovanna Esposito
- Division of Emergency Medicine, Umberto I Hospital, Nocera Inferiore, SA, Italy
| | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Antonello D'Andrea
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy. .,Division of Cardiology, Umberto I Hospital, Nocera Inferiore, SA, Italy.
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Piccirillo F, Watanabe M, Di Sciascio G. Diagnosis, treatment and predictors of prognosis of myocarditis. A narrative review. Cardiovasc Pathol 2021; 54:107362. [PMID: 34192559 DOI: 10.1016/j.carpath.2021.107362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/31/2022] Open
Abstract
Although it has been recognized for almost two centuries, myocarditis is still a challenging diagnosis due to the wide heterogeneity of its clinical manifestations and evolution. Moreover, the diagnostic gold standard, endomyocardial biopsy (EMB), is infrequently used, making hard to determine the exact incidence of myocarditis. Clinical presentation includes a wide range of symptoms, ranging from asymptomatic or subclinical disease with mild dyspnea and chest pain to sudden death, due to cardiogenic shock or malignant ventricular arrhythmias. Equally, the evolution of myocarditis largely varies: albeit short-term prognosis is usually good, with complete or partial recovery, dilated cardiomyopathy with chronic heart failure is the major long-term consequence of myocarditis, developing often several years after the acute onset. This narrative review aims to summarize the current knowledge about myocarditis, with a particular attention to predictors of short- and long-term prognosis, in order to provide a rational and practical approach to the diagnosis, evaluation and treatment of suspected myocarditis.
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Affiliation(s)
- Francesco Piccirillo
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy.
| | - Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Germano Di Sciascio
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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Rroku A, Kottwitz J, Heidecker B. Update on myocarditis - what we know so far and where we may be heading. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:455–467. [PMID: 32319308 DOI: 10.1177/2048872620910109] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Andi Rroku
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | | | - Bettina Heidecker
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
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Sacharczuk W, Dankowski R, Szyszka A. The usefulness of echocardiography in the diagnosis of myocarditis in a young man after sudden cardiac arrest. Echocardiography 2021; 38:686-692. [PMID: 33675256 DOI: 10.1111/echo.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/05/2021] [Accepted: 02/20/2021] [Indexed: 11/30/2022] Open
Abstract
The diagnosis of acute myocarditis (AM) remains challenging because of its diverse clinical manifestations. Thus, a wide range of diagnostic tests may be warranted. Although cardiac magnetic resonance (CMR) is the preferred imaging technique, it may not be applicable in the acute AM phase. Our case report highlights the usefulness and diagnostic accuracy of echocardiographic examination. In the first 2-dimensional echocardiography, the focal echobright was presented. A reduced value of global longitudinal strain and regional disturbances of segmental myocardial strain, both longitudinal and circumferential, in the epicardial layer, were detected with a good correlation with CMR results.
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Affiliation(s)
- Wioletta Sacharczuk
- 2nd Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Rafał Dankowski
- 2nd Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Szyszka
- 2nd Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
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Management of Patients With Giant Cell Myocarditis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 77:1122-1134. [PMID: 33632487 DOI: 10.1016/j.jacc.2020.11.074] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/22/2022]
Abstract
Giant cell myocarditis is a rare, often rapidly progressive and potentially fatal, disease due to T-cell lymphocyte-mediated inflammation of the myocardium that typically affects young and middle-aged adults. Frequently, the disease course is marked by acute heart failure, cardiogenic shock, intractable ventricular arrhythmias, and/or heart block. Diagnosis is often difficult due to its varied clinical presentation and overlap with other cardiovascular conditions. Although cardiac biomarkers and multimodality imaging are often used as initial diagnostic tests, endomyocardial biopsy is required for definitive diagnosis. Combination immunosuppressive therapy, along with guideline-directed medical therapy, has led to a paradigm shift in the management of giant cell myocarditis resulting in an improvement in overall and transplant-free survival. Early diagnosis and prompt management can decrease the risk of transplantation or death, which remain common in patients who present with cardiogenic shock.
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Garcia-Vives E, Rodriguez-Palomares JF, Harty L, Solans-Laque R, Jayne D. Heart Disease in Eosinophilic Granulomatosis with Polyangiitis (EGPA) Patients: a screening approach proposal. Rheumatology (Oxford) 2021; 60:4538-4547. [PMID: 33493294 DOI: 10.1093/rheumatology/keab027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To define the pattern of cardiac involvement in eosinophilic granulomatosis and polyangiitis (EGPA) and propose an algorithm for heart disease screening. METHODS Retrospective study of EGPA patients attending a specialized vasculitis clinic (1989-2016). Clinical characteristics and cardiovascular evaluation (CE) results (serum troponin, ECG, echocardiography and cardiac magnetic resonance) were collected and compared according to symptoms and inflammatory cardiac disease (ICD). RESULTS 131 EGPA patients were included, of whom 96 (73%) had undergone CE. The median age was 50 [IQR 38-58] years and 36% showed ANCA+. Asthma preceded diagnosis by a median of 97 [36-240] months. Among the 96 patients who underwent CE, 43% were symptomatic, being dyspnea (47%) and chest pain (29%) the predominant symptoms. In asymptomatic patients, CE reported abnormalities in 45% of cases with a subsequent earlier diagnosis (4 vs 11 months). Overall, 27 patients had EGPA-related ICD (rICD) that was already present at diagnosis in 20 cases, preceded it in 2 cases and developed later in 5. EGPA-rICD patients were younger (46 vs 50 years; p= 0.04), had more frequently abnormal ECG (30.8% vs 2.1%; p< 0.001), negative ANCA (85% vs 69%; NS), higher BVAS score (3 vs 1; p= 0.005), higher eosinophil count (5.60 vs 1.60x109/l; p= 0.029) and higher C reactive protein (52 vs 15 mg/l; p= 0.017). Overall, 11% of cases with EGPA-rICD were asymptomatic. CONCLUSION In our study, 45% of asymptomatic patients had an abnormal baseline cardiac evaluation, which allowed an earlier diagnosis of cardiac disease. We recommend prompt cardiac screening in all EGPA patients, instead of a symptoms-guided algorithm.
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Affiliation(s)
- Eloi Garcia-Vives
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - J F Rodriguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, CIBER-CV, Vall d'Hebrón Institut de recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Len Harty
- Rheumatology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Roser Solans-Laque
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - David Jayne
- Nephrology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
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50
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Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med 2020; 31:163-169. [PMID: 33383171 PMCID: PMC7965406 DOI: 10.1016/j.tcm.2020.12.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/03/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.
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Affiliation(s)
- Shereif H Rezkalla
- Department of Cardiology & Cardiovascular Research, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449 USA; Adjunct Professor, University of Wisconsin, School of Medicine USA.
| | - Robert A Kloner
- Chief Science Officer, Scientific Director of Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, CA USA; Professor of Medicine (Clinical Scholar), Cardiovascular Division, Dept. of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA USA.
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