1
|
Esmel-Vilomara R, Riaza L, Dolader P, Sabaté-Rotés A, Rosés-Noguer F, Gran F. New-onset heart failure in infants: when the aetiological diagnosis becomes a challenge. Eur J Pediatr 2024; 183:493-498. [PMID: 37843615 DOI: 10.1007/s00431-023-05286-5] [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: 06/26/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/17/2023]
Abstract
This study aimed to report the findings of cardiac magnetic resonance imaging (CMR) with quantitative mappings in infants presenting with new-onset heart failure, as well as to assess the capabilities of endomyocardial biopsy (EMB) and CMR in detecting inflammatory cardiomyopathies and determining their etiology. In a prospective analysis of infants who underwent CMR with tissue mappings, EMB, and genetic testing, the sample was categorized into two groups: those with inflammatory cardiomyopathy and negative genetics (indicative of possible myocarditis) and those with positive genetics (indicative of possible dilated cardiomyopathy). All patients exhibited similar clinical presentations, echocardiographic dysfunction, and elevated troponins and NT-proBNP levels. Additionally, they all met the diagnostic criteria for inflammatory cardiomyopathy based on EMB findings (≥14 mononuclear cells, ≥7 T-lymphocytes/mm2). EMB results unveiled significant differences in the presence of inflammation and edema between the two groups, with higher troponin levels correlating with increased inflammation. Notably, when focusing on CMR, neither the classic criteria nor the 2018 Lake Louise criteria (LLC) could effectively differentiate between the two groups. Only late gadolinium enhancement (LGE) appeared to be associated with myocarditis in this cohort, while other LLC and tissue mappings did not exhibit a similar correlation. Importantly, there was no observed correlation between the inflammation detected through EMB and CMR. CONCLUSIONS The onset of heart dysfunction in infants can result from either inherited factors or viral infections, both of which may involve inflammation. However, the precise role of EMB and CMR in determining the etiology of such cases remains poorly defined. While CMR demonstrates high sensitivity in detecting inflammation, our experience suggests that it may not effectively differentiate between these two groups. A comprehensive diagnostic approach is essential when addressing this challenge, which includes considering EMB (with attention to the number of T-lymphocytes and the presence of oedema), specific CMR criteria, notably LGE and tissue mappings, as well as the identification of viral agents in cardiac tissue and troponin levels. Additionally, genetic tests should be conducted when evaluating these patients. WHAT IS KNOWN • EMB is the gold standard diagnostic test for myocarditis but it is not universally accepted. • The diagnostic value of the 2018-LLC in pediatric patients is still undefined. WHAT IS NEW • Both EMB and CMR may show inflammation in infants with new-onset heart failure of any aetiology. • A global approach should be used when facing this diagnostic challenge, including the EMB (number of T-lymphocytes and oedema), some CMR criteria, specially LGE and mappings, the detection of viral agents in cardiac tissue and troponins. Genetic tests should also be performed when studying these patients.
Collapse
Affiliation(s)
- Roger Esmel-Vilomara
- Paediatric Cardiology, Vall d'Hebron Hospital Campus, Barcelona, Spain.
- Paediatric Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Lucía Riaza
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Paediatric Radiology, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - Paola Dolader
- Paediatric Cardiology, Vall d'Hebron Hospital Campus, Barcelona, Spain
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Sabaté-Rotés
- Paediatric Cardiology, Vall d'Hebron Hospital Campus, Barcelona, Spain
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Rosés-Noguer
- Paediatric Cardiology, Vall d'Hebron Hospital Campus, Barcelona, Spain
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Gran
- Paediatric Cardiology, Vall d'Hebron Hospital Campus, Barcelona, Spain
- Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
2
|
Callegari A, Quandt D, Schmitz A, Klingel K, Balmer C, Dave H, Kretschmar O, Knirsch W. Findings and Outcome of Transcatheter Right Ventricular Endomyocardial Biopsy and Hemodynamic Assessment in Children with Suspected Myocarditis or Cardiomyopathy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10406. [PMID: 36012045 PMCID: PMC9408529 DOI: 10.3390/ijerph191610406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The study objective is assessing findings and outcome in children with suspected cardiomyopathy (CMP) or myocarditis undergoing cardiac catheterization with transcatheter right ventricular endomyocardial biopsy (RV-EMB). METHODS All consecutive children undergoing cardiac catheterization with RV-EMB for suspected CMP/myocarditis between 2002-2021 were analysed regarding clinical presentation, cardiac biomarkers, periprocedural management, hemodynamic, histological/immunohistological findings, and outcome. RESULTS Eighty-five RV-EMBs were performed in 81 patients at a median age of 6.8 (IQR 9.9) years and a bodyweight of 20 (32.2) kg. Histological/immunohistological findings of RV-EMB revealed dilated CMP in 10 (12%), chronic myocarditis in 28 (33%), healing myocarditis in 5 (6%), acute myocarditis in 9 (11%), other heart muscle diseases in 23 (27%) (7 restrictive CMP, 5 hypertrophic CMP, 4 toxic/anthracycline-induced CMP, 4 endocardfibroelastosis, 1 arrhythmogenic right ventricular CMP, 1 laminin CMP, 1 haemangioma), no conclusive histology in 7 (8%), and normal histology in 3 (4%) patients. Median LVEDP was 17 mmHg (IQR 9), LAP 15 mmHg (10), and PVR 1.83 (1.87) Wood Units/m2. There were 3 major complications (3%), all patients recovered without any sequelae. At follow-up (median 1153, IQR 1799 days) 47 (59%) patients were alive, 11 (13%) dead, 15 (18%) underwent cardiac transplantation, and 8 (9%) were lost to follow-up. Death/cardiac transplantation occurred within 3 years from RV-EMB. All patients with an acute myocarditis survived. NT-pro-BNP, echo parameters, and invasive hemodynamics correlate independently with death/cardiac transplant. CONCLUSION Hemodynamic invasive data and morphological findings in RV-EMB complete clinical diagnosis in children with suspected CMP/myocarditis and provide important information for further clinical management.
Collapse
Affiliation(s)
- Alessia Callegari
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Daniel Quandt
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Achim Schmitz
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
- Division of Anesthesia, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, Eberhard Karls University Tübingen, 72074 Tubingen, Germany
| | - Christian Balmer
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Hitendu Dave
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
- Congenital Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Oliver Kretschmar
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Centre, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| |
Collapse
|
3
|
Gran F, Fidalgo A, Dolader P, Garrido M, Navarro A, Izquierdo-Blasco J, Balcells J, Codina-Sola M, Fernandez-Alvarez P, Sabaté-Rotés A, Betrián P, Fernández-Doblas J, Abella R, Roses-Noguer F. Differences between genetic dilated cardiomyopathy and myocarditis in children presenting with severe cardiac dysfunction. Eur J Pediatr 2022; 181:287-294. [PMID: 34286374 PMCID: PMC8294227 DOI: 10.1007/s00431-021-04175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/18/2021] [Accepted: 06/19/2021] [Indexed: 11/24/2022]
Abstract
Acute myocarditis is an inflammatory disease of the myocardium, and it can present as severe heart failure in children. Differential diagnosis with genetic cardiomyopathy can be difficult. The objective of this study is to identify patterns of clinical presentation and to assess invasive and non-invasive measures to differentiate patients with acute myocarditis from patients with dilated genetic cardiomyopathy. We performed a retrospective descriptive study of all paediatric patients (0-16 years old) that presented with new-onset heart failure with left ventricle ejection fraction < 35% in whom we performed an endomyocardial biopsy (EMB) during the period from April 2007 to December 2020. The patients were classified into two groups: Group 1 included 18 patients with myocarditis. Group 2 included 9 patients with genetic cardiomyopathy. Findings favouring a diagnosis of myocarditis included a fulminant or acute presentation (77.8% vs 33.3%, p = 0.01), higher degree of cardiac enzyme elevation (p = 0.011), lower left ventricular dimension z-score (2.2 vs 5.4, p = 0.03) increase of ventricular wall thickness (88.8% vs 33.3%, p = 0.03) and oedema in the EMB. Seven (77.8%) patients with genetic cardiomyopathy had inflammation in the endomyocardial biopsy fulfilling the diagnostic criteria of inflammatory cardiomyopathy.Conclusion: Differentiating patients with a myocarditis from those with genetic cardiomyopathy can be challenging, even performing an EMB. Some patients with genetic cardiomyopathy fulfil the diagnostic criteria of inflammatory cardiomyopathy. Using invasive and non-invasive measures may be useful to develop a predictive model to differentiate myocarditis from genetic cardiomyopathy. What is Known: • Acute myocarditis could present with cardiogenic shock in paediatric patients. • Parvovirus B19 is the main cause of myocarditis in this population. What is New: • Current diagnostic criteria for myocarditis have limited use in paediatric patients presenting with new-onset heart failure. • Some patients with a genetic cardiomyopathy and a new-onset heart failure fulfill the diagnostic criteria of inflammatory cardiomyopathy.
Collapse
Affiliation(s)
- Ferran Gran
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Andrea Fidalgo
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Paola Dolader
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Marta Garrido
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Alexandra Navarro
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jaume Izquierdo-Blasco
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Joan Balcells
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marta Codina-Sola
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Paula Fernandez-Alvarez
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Anna Sabaté-Rotés
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Pedro Betrián
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Joaquín Fernández-Doblas
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Raúl Abella
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ferran Roses-Noguer
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| |
Collapse
|
4
|
Shweiki D. Contemplating on the Etiology of COVID-19 Severity and Mortality Sex Differences. GENDER AND THE GENOME 2020. [DOI: 10.1177/2470289720970203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
COVID-19 displays a sex-biased behavior with a higher rate of intensity and mortality in men. In that sense, COVID-19 deflects-off the typical trend of many viral infections which are characterized by a higher rate of intensity and prevalence in males, yet a higher female mortality rate. Severity and mortality rates of COVID-19 are associated with several underlying diseases, which exhibit significant self-sufficient male-biased dimorphism, thus are at times hypothesized to be the ones responsible to tilt mortality balance toward higher men death in COVID-19. Yet, similar comorbidities prevail in other viral infections, raising curiosity to what makes COVID-19 unique? The answer may lay in the involvement of renin-angiotensin system and ACE2 receptor in COVID-19 progression, 2 players which are significant contributors to the fatality of COVID-19. A structured difference is evident in the expression and function of RAS and ACE2 between the sexes, presumably tipping over mortality rate tendency toward male-risk factor.
Collapse
Affiliation(s)
- Dorit Shweiki
- Bioinformatics Program, School of Computer Science, The Academic College of Tel Aviv-Yaffo, Tel Aviv, Israel
| |
Collapse
|
5
|
Jarrell DK, Vanderslice EJ, VeDepo MC, Jacot JG. Engineering Myocardium for Heart Regeneration-Advancements, Considerations, and Future Directions. Front Cardiovasc Med 2020; 7:586261. [PMID: 33195474 PMCID: PMC7588355 DOI: 10.3389/fcvm.2020.586261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/31/2020] [Indexed: 12/28/2022] Open
Abstract
Heart disease is the leading cause of death in the United States among both adults and infants. In adults, 5-year survival after a heart attack is <60%, and congenital heart defects are the top killer of liveborn infants. Problematically, the regenerative capacity of the heart is extremely limited, even in newborns. Furthermore, suitable donor hearts for transplant cannot meet the demand and require recipients to use immunosuppressants for life. Tissue engineered myocardium has the potential to replace dead or fibrotic heart tissue in adults and could also be used to permanently repair congenital heart defects in infants. In addition, engineering functional myocardium could facilitate the development of a whole bioartificial heart. Here, we review and compare in vitro and in situ myocardial tissue engineering strategies. In the context of this comparison, we consider three challenges that must be addressed in the engineering of myocardial tissue: recapitulation of myocardial architecture, vascularization of the tissue, and modulation of the immune system. In addition to reviewing and analyzing current progress, we recommend specific strategies for the generation of tissue engineered myocardial patches for heart regeneration and repair.
Collapse
Affiliation(s)
- Dillon K Jarrell
- Jacot Laboratory for Pediatric Regenerative Medicine, Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ethan J Vanderslice
- Jacot Laboratory for Pediatric Regenerative Medicine, Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Mitchell C VeDepo
- Jacot Laboratory for Pediatric Regenerative Medicine, Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jeffrey G Jacot
- Jacot Laboratory for Pediatric Regenerative Medicine, Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| |
Collapse
|