Ventricular assist device use for the treatment of acute viral myocarditis

Mechanical Circulatory Support in Pediatric Myocarditis: Support Strategies and Outcomes in a Nationally Representative Cohort

Background

Myocarditis is a common cause of pediatric heart failure which may require mechanical circulatory support (MCS). The purpose of this study is to describe MCS strategies used in a nationwide cohort of pediatric patients with myocarditis, identify trends over time, and compare outcomes between MCS strategies.

Methods

This study utilized the Kids' Inpatient Database (KID), a national sample of administrative discharge data. KID admissions from 2003-2016 were queried using ICD-9/10 codes to identify those with a diagnosis of myocarditis. MCS outcomes were compared using logistic regression.

Results

Of 5,661 admissions for myocarditis, MCS was used in 424 (7.5%), comprised of extracorporeal membrane oxygenation (ECMO) in 312 (73.6%), including 32 (10.2%) instances of extracorporeal cardiopulmonary resuscitation (ECPR), temporary ventricular assist devices (tVAD) in 28 (6.6%), durable VAD (dVAD) in 42 (9.9%) and combination MCS in 42 (9.9%). MCS use increased over time (p=0.031), but MCS strategies did not significantly change. Mortality was high in the MCS group (28.3%). There was no difference in odds of death in the VAD only or combination MCS group compared to the non-ECPR ECMO group (p=0.07 and p=0.65, respectively).

Conclusion

MCS is used in 1 in 13 pediatric myocarditis cases, and MCS use is increasing over time with ECMO remaining the most frequently used modality. Mortality remains high in patients that receive MCS but does not differ between those receiving VAD or combination MCS as compared to non-ECPR ECMO on unadjusted analysis. Further prospective analysis is required to evaluate the relative effectiveness of MCS modalities in this disease.

SARS-CoV-2-Induced Myocarditis: A State-of-the-Art Review

In this review, we investigated whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can directly cause myocarditis with severe myocardial damage induced by viral particles. A review of the major data published from 2020 to 2022 was performed by consulting the major databases alongside first-hand experiences that emerged from the cardiac biopsies and autopsy examinations of patients who died of SARS-CoV-2 infections. From this study, a significantly large amount of data suggests that the Dallas criteria were met in a residual percentage of patients, demonstrating that SARS-CoV-2 myocarditis was a rare clinical and pathological entity that occurred in a small percentage of subjects. All cases described here were highly selected and subjected to autopsies or endomyocardial biopsies (EMBs). The most important discovery, through the detection of the SARS-CoV-2 genome using the polymerase chain reaction, consisted in the presence of the viral genome in the lung tissue of most of the patients who died from COVID-19. However, the discovery of the SARS-CoV-2 viral genome was a rare event in cardiac tissue from autopsy findings of patients who died of myocarditis It is important to emphasize that myocardial inflammation alone, as promoted by macrophages and T cell infiltrations, can be observed in noninfectious deaths and COVID-19 cases, but the extent of each cause is varied, and in neither case have such findings been reported to support clinically relevant myocarditis. Therefore, in the different infected vs. non-infected samples examined, none of our findings provide a definitive histochemical assessment for the diagnosis of myocarditis in the majority of cases evaluated. We report evidence suggesting an extremely low frequency of viral myocarditis that has also been associated with unclear therapeutic implications. These two key factors strongly point towards the use of an endomyocardial biopsy to irrefutably reach a diagnosis of viral myocarditis in the context of COVID-19.

Sex and gender differences in myocarditis and dilated cardiomyopathy: An update

In the past decade there has been a growing interest in understanding sex and gender differences in myocarditis and dilated cardiomyopathy (DCM), and the purpose of this review is to provide an update on this topic including epidemiology, pathogenesis and clinical presentation, diagnosis and management. Recently, many clinical studies have been conducted examining sex differences in myocarditis. Studies consistently report that myocarditis occurs more often in men than women with a sex ratio ranging from 1:2-4 female to male. Studies reveal that DCM also has a sex ratio of around 1:3 women to men and this is also true for familial/genetic forms of DCM. Animal models have demonstrated that DCM develops after myocarditis in susceptible mouse strains and evidence exists for this progress clinically as well. A consistent finding is that myocarditis occurs primarily in men under 50 years of age, but in women after age 50 or post-menopause. In contrast, DCM typically occurs after age 50, although the age that post-myocarditis DCM occurs has not been investigated. In a small study, more men with myocarditis presented with symptoms of chest pain while women presented with dyspnea. Men with myocarditis have been found to have higher levels of heart failure biomarkers soluble ST2, creatine kinase, myoglobin and T helper 17-associated cytokines while women develop a better regulatory immune response. Studies of the pathogenesis of disease have found that Toll-like receptor (TLR)2 and TLR4 signaling pathways play a central role in increasing inflammation during myocarditis and in promoting remodeling and fibrosis that leads to DCM, and all of these pathways are elevated in males. Management of myocarditis follows heart failure guidelines and there are currently no disease-specific therapies. Research on standard heart failure medications reveal important sex differences. Overall, many advances in our understanding of the effect of biologic sex on myocarditis and DCM have occurred over the past decade, but many gaps in our understanding remain. A better understanding of sex and gender effects are needed to develop disease-targeted and individualized medicine approaches in the future.

Viral Myocarditis-Incidence, Diagnosis and Management

Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.

Use of the Impella 5.0 Device as a Bridge to Recovery in Adult Fulminant Viral Myocarditis

We present a case of a 48-year-old female patient successfully bridged to recovery with the Impella 5.0 microaxial pump (Abiomed, Danvers, MA USA) after presenting with cardiogenic shock secondary to acute fulminant viral myocarditis. After 1 week of flu-like symptoms, the patient presented to her community emergency department with chest pain and hypotension. A diagnosis of inferior ST elevation myocardial infarction was made; subsequent angiography demonstrated normal coronary arteries and a left ventricular ejection fraction of 10%. A provisional diagnosis of viral myocarditis was made. As her condition deteriorated further, she underwent insertion of an Impella 5.0 after failure of supportive medical therapy. Myocardial recovery occurred, and the Impella was removed after 1 week. After a prolonged cardiac intensive care unit stay requiring temporary hemodialysis, the patient recovered sufficiently to tolerate device explant, transfer to the recovery ward, and ultimate discharge home. This case report highlights the benefit of mechanical circulatory support in a patient with cardiogenic shock from viral myocarditis as well as some of the complications that can occur in this critically ill subset of patients.

WITHDRAWN: Herbal medicines for viral myocarditis

The editors of Cochrane Heart consider this title as low priority for the current portfolio of the Heart Group and therefore this title is not open to a new author team.

The editorial group responsible for this previously published document have withdrawn it from publication.

A Case of Clozapine-Induced Myocarditis in a Young Patient with Bipolar Disorder

We present a case of drug-induced myocarditis manifesting as acute heart failure in a young patient with bipolar disorder being treated for depression. The case describes a 20-year-old man being treated in the psychiatry ward for worsening depression when he started complaining of chest pain and shortness of breath. His list of medications included clozapine, lithium, lorazepam, and haloperidol. The main findings on physical examination were tachycardia, low-grade fever, crackles in both lung bases on auscultation, and the absence of any notable edema. Abnormal labs included a troponin of 0.9, with a CK of 245 and CK-MB of 3.1. An ECG revealed sinus tachycardia and left anterior fascicular block (LAFB). An echocardiogram revealed global hypokinesis, severe left ventricular dysfunction with an ejection fraction estimated at 20%. The patient had an admitting diagnosis of acute left ventricular systolic dysfunction likely secondary to drug-induced myocarditis (suspect clozapine) versus acute coronary syndrome. He was managed conservatively and transferred to another facility for endomyocardial biopsy confirming myocarditis. This case is an example of one of the most typical presentations of suspected drug-induced acute myocarditis and will hopefully prompt the reader to think of this underdiagnosed entity in the right clinical setting.

Herbal medicines for viral myocarditis

BACKGROUND

Herbal medicines are used as treatment for viral diseases such as viral myocarditis, and numerous clinical trials have been conducted to investigate their efficacy. Despite this wealth of evidence, the role of herbal medicines in the treatment of viral myocarditis has yet to be established. This is an update of a review published in 2012.

OBJECTIVES

To assess the benefits and harms of herbal medicines on clinical (e.g. mortality, incidence of complications) and indirect outcomes (e.g. cardiac function, biochemical response) in patients with viral myocarditis, irrespective of the patients' age, gender or type (including acute and chronic viral myocarditis).

SEARCH METHODS

We searched CENTRAL (2013, Issue 1) on The Cochrane Library, MEDLINE (Ovid, 1946 to January Week 4 2013), EMBASE (Ovid, 1980 to 2013 Week 04) and LILACS (Bireme) on 1 February 2013. We previously searched The Chinese Biomedical Database (1979 to 2011), China National Knowledge Infrastructure (1979 to 2011), Chinese VIP Information (1989 to 2011), Chinese Academic Conference Papers Database and Chinese Dissertation Database (1980 to 2011), AMED (June 2011) and the Cochrane Complementary Medicine Field Trials Register (June 2011). We handsearched Chinese journals and conference proceedings. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of herbal medicines (with a minimum duration of seven days of treatment) compared with placebo, no intervention, or conventional interventions were included. Trials of herbal medicine plus a conventional drug versus the drug alone were also included. We included only trials that reported an adequate description of allocation sequence generation.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and evaluated trial quality. Information on adverse effects was collected from the trial reports.

MAIN RESULTS

We did not identify any new trials with the updated search in February 2013. The 2011 update of this review included twenty randomised controlled trials involving 2177 people. All the trials were conducted and published in China. The controls included anti-arrhythmic drugs, corticosteroids, and antiviral therapies such as ribavirin or interferon. Combining the risk of bias for random sequence generation, allocation concealment, selective reporting, and incomplete outcome data, we assessed the included trials as being at a high risk of bias. Thirteen different herbal medicines were tested in the included trials. One of the trials reported outcomes on mortality. The trials reported electrocardiogram results, levels of myocardial enzymes, cardiac function, and adverse effects.Compared with supportive therapy, Astragalus membranaceus injection did not show a significant reduction in the number of patients that died of cardiac failure.A meta-analysis showed a significant effect ofAstragalus membranaceus injection plus supportive therapy on the number of participants with an abnormal electrocardiogram (RR 0.28, 95% CI 0.13 to 0.61), ST-T changes (RR 0.72, 95% CI 0.54 to 0.95), creatine phosphate kinase (CPK) levels (MD -21.54, 95% CI -33.80 to -9.28), and lactate dehydrogenase (LDH) levels (MD -30.33, 95% CI -46.78 to -13.88).Shengmai injection plus supportive therapy showed a significant effect on the number of patients with an abnormal electrocardiogram (RR 0.11, 95% CI 0.01 to 0.86), CPK levels (MD -103.90, 95% CI -114.97 to -92.83), LDH levels (MD -34.60, 95% CI -51.25 to -17.95), and on myocardial enzyme CK-MB levels (MD -10.87, 95% CI -14.50 to -7.24). Shengmai decoction plus supportive therapy showed a significant effect on improving quality of life measured by the SF-36 (MD 40.20, 95% CI 18.13 to 62.27) compared to supportive therapy. Data on adverse events were only available from six of the included trials and no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

Since no new trials were identified in the updated search in 2013, the conclusions remain the same as they were in 2012. There is no evidence of benefit of herbal medicine on all cause mortality. Some herbal medicines may lead to improvement of ventricular premature beat, electrocardiogram, levels of myocardial enzymes, and cardiac function in viral myocarditis. However, these findings should be interpreted with care, due to the risk of bias of the included studies, small sample size, and limited number of trials on individual herbs. Further robust trials are needed to explore the use of herbal medicines for viral myocarditis.

Sex and gender differences in myocarditis and dilated cardiomyopathy

Heart failure due to nonischemic dilated cardiomyopathy (DCM) contributes significantly to the global burden of cardiovascular disease. Myocarditis is, in turn, a major cause of acute DCM in both men and women. However, recent clinical and experimental evidence suggests that the pathogenesis and prognosis of DCM differ between the sexes. This seminar provides a contemporary perspective on the immune mediators of myocarditis, including interdependent elements of the innate and adaptive immune response. The heart's acute response to injury is influenced by sex hormones that appear to determine the subsequent risk of chronic DCM. Preliminary data suggest additional genetic variations may account for some of the differences in epidemiology, left ventricular recovery, and survival between men and women. We highlight the gaps in our knowledge regarding the management of women with acute DCM and discuss emerging therapies, including bromocriptine for the treatment of peripartum cardiomyopathy.

Herbal medicines for viral myocarditis

BACKGROUND

Herbal medicines are being used as a treatment for viral diseases such as viral myocarditis and numerous clinical trials have been conducted to investigate their efficacy. Despite this wealth of evidence, the role of herbal medicines in the treatment of viral myocarditis is yet to be established. This is an update of the review published in 2010.

OBJECTIVES

To assess the effects of herbal medicines on clinical (for example mortality, incidence of complications) and indirect outcomes (for example cardiac function, biochemical response) in patients with viral myocarditis.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2011, Issue 2), MEDLINE (January 1966 to June 2011), EMBASE (January 1998 to June 2011), Chinese Biomedical Database (1979 to 2011), China National Knowledge Infrastructure (1979 to 2011), Chinese VIP Information (1989 to 2011), Chinese Academic Conference Papers Database and Chinese Dissertation Database (1980 to 2011), AMED (June 2011), LILACS (June 2011), and the Cochrane Complementary Medicine Field Trials Register. We handsearched Chinese journals and conference proceedings. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of herbal medicines (with a minimum of seven days treatment duration) compared with placebo, no intervention, or conventional interventions were included. Trials of herbal medicine plus conventional drug versus drug alone were also included. Only trials that reported an adequate description of allocation sequence generation were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and evaluated trial quality. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty randomised controlled trials involving 2177 people were included. All trials were conducted and published in China. The controls included anti-arrhythmic drugs, corticosteroids, and antiviral therapies such as ribavirin or interferon. Combining the risk of bias on random sequence generation, allocation concealment, selective reporting, and incomplete outcome data, the included trials were assessed to be at high risk of bias. Thirteen different herbal medicines were tested in the included trials. None of the trials reported outcomes on mortality. The trials reported electrocardiogram results, level of myocardial enzymes, cardiac function, and adverse effects.A meta-analysis showed a significant effect of Astragalus membranaceus injection plus supportive therapy on the number of patients with an abnormal electrocardiogram (RR 0.28, 95% CI 0.13 to 0.61), ST-T changes (RR 0.72, 95% CI 0.54 to 0.95), creatine phosphate kinase (CPK) levels (MD -21.54, 95% CI -33.80 to -9.28), and lactate dehydrogenase (LDH) levels (MD -30.33, 95% CI -46.78 to -13.88).Shengmai injection plus supportive therapy showed a significant effect on the number of patients with an abnormal electrocardiogram (RR 0.11, 95% CI 0.01 to 0.86), CPK levels (MD -103.90, 95% CI -114.97 to -92.83), LDH levels (MD -34.60, 95% CI -51.25 to -17.95), and on myocardial enzyme CK-MB levels (MD -10.87, 95% CI -14.50 to -7.24). Shengmai decoction plus supportive therapy showed a significant effect on improving quality of life measured by the SF-36 (MD 40.20, 95% CI 18.13 to 62.27) compared to supportive therapy. Data on adverse events were only available from six of the included trials and no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

Some herbal medicines may lead to improvement of ventricular premature beat, electrocardiogram, level of myocardial enzymes, and cardiac function in viral myocarditis. However, these findings should be interpreted with care due to the high risk of bias of the included studies, small sample size, and limited number of trials on individual herbs. Further robust trials are needed to explore the use of herbal medicines in viral myocarditis.

Myocarditis

Myocarditis is an underdiagnosed cause of acute heart failure, sudden death, and chronic dilated cardiomyopathy. In developed countries, viral infections commonly cause myocarditis; however, in the developing world, rheumatic carditis, Trypanosoma cruzi, and bacterial infections such as diphtheria still contribute to the global burden of the disease. The short-term prognosis of acute myocarditis is usually good, but varies widely by cause. Those patients who initially recover might develop recurrent dilated cardiomyopathy and heart failure, sometimes years later. Because myocarditis presents with non-specific symptoms including chest pain, dyspnoea, and palpitations, it often mimics more common disorders such as coronary artery disease. In some patients, cardiac MRI and endomyocardial biopsy can help identify myocarditis, predict risk of cardiovascular events, and guide treatment. Finding effective therapies has been challenging because the pathogenesis of chronic dilated cardiomyopathy after viral myocarditis is complex and determined by host and viral genetics as well as environmental factors. Findings from recent clinical trials suggest that some patients with chronic inflammatory cardiomyopathy have a progressive clinical course despite standard medical care and might improve with a short course of immunosuppression.

Successful weaning and explantation of the Heartmate II left ventricular assist device

BACKGROUND

Ventricular assist devices (VADs) are used in cases of heart failure refractory to medical therapy. Most VADs are used as a bridge to heart transplantation; however, in certain cases, myocardial function recovers and VADs can be explanted after the patient is weaned. The objectives of this study were to describe patients who required Heartmate II VAD insertion, followed by myocardial recovery and explanation in a quaternary heart centre.

METHODS

Patients who had a VAD explanted were identified in the mechanical support institutional database and their outcomes were analyzed. Clinical examinations, biochemical markers, and serial echocardiograms were used to demonstrate myocardial recovery.

RESULTS

Seventeen patients had a Heartmate II VAD inserted between 2008 and 2010. Four patients underwent successful weaning and subsequent VAD explantation. Etiology of decompensated heart failure was idiopathic dilated cardiomyopathy (n = 1), ischemic (n = 1), or myocarditis (n = 2). Mean age was 35.3 years. Patients were supported for 213 days (range 70-293 days) and were in New York Heart Association class I in the community before explantation. The devices were explanted via a minimally invasive approach, without cardiopulmonary bypass. All patients survived explantation and were discharged alive from hospital after an average of 5.7 ± 1.5 days post pump explantation. No adverse events were reported after explantation. Only one patient required allogenic blood transfusion after the procedure.

CONCLUSIONS

Patients requiring VAD support for myocardial failure can undergo significant reverse remodelling. Explantation can lead to optimal outcome with minimal morbidity. Methods for assessment of reverse remodelling, weaning protocol, and optimal timing of explantation remain under evaluation.

Effectiveness of mechanical circulatory support in children with acute fulminant and persistent myocarditis

BACKGROUND

Acute fulminant myocarditis is a life-threatening disease in children. A limited number of reports suggest that mechanical circulatory support (MCS) may be used to successfully bridge children with acute fulminant myocarditis to recovery or transplantation. We evaluated the effectiveness of MCS in children with myocarditis and identified risk factors associated with adverse outcomes.

METHODS AND RESULTS

Between 2001 and 2009, 16 children were treated for myocarditis at our institution; each child received MCS provided by extracorporeal membrane oxygenation, ventricular assist device(s), or both. Of these patients, 75% (12/16) survived: 7 recovered ventricular function, and 5 underwent successful orthotopic heart transplantation. In patients who were bridged to recovery, mean left ventricular ejection fraction significantly improved from initiation to termination of MCS (20 ± 9.3% to 62 ± 5%; P = .0004). Viral pathogens were detected in 11 patients by polymerase chain reaction, and viral presence was associated with death or need for transplantation (P = .011). Upon histologic analysis, absence of viral infection and lack of myocardial inflammation were associated with recovery (P values .011 and .044, respectively).

CONCLUSIONS

In children with acute fulminant and persistent myocarditis, MCS is a life-saving treatment strategy, particularly in the absence of viral infection.

Herbal medicines for viral myocarditis

BACKGROUND

Herbal medicines are being used for treating viral diseases including viral myocarditis, and many controlled trials have been done to investigate their efficacy.

OBJECTIVES

To assess the effects of herbal medicines on clinical and indirect outcomes in patients with viral myocarditis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2009, MEDLINE (January 1966 - July 2009), EMBASE (January 1998 - July 2009), Chinese Biomedical Database (1979 - 2009), China National Knowledge Infrastructure (1979 - 2009), Chinese VIP Information (1989 - 2009), Chinese Academic Conference Papers Database and Chinese Dissertation Database (1980 - 2009), AMED (1985 - 2009), LILACS accessed in July 2009 and the trials register of the Cochrane Complementary Medicine Field. We handsearched Chinese journals and conference proceedings. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of herbal medicines (with a minimum of seven days treatment duration) compared with placebo, no intervention, or conventional interventions were included. Trials of herbal medicine plus conventional drug versus drug alone were also included. Only trials that reported adequate description of allocation sequence generation were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and evaluated trial quality. Adverse effects information was collected from the trials.

MAIN RESULTS

Fourteen randomised trials involving 1463 people were included. All trials were conducted and published in China. Quality of the trials was assessed to be low. No trial had diagnosis of viral myocarditis confirmed histologically, and only a few trials attempted to establish viral aetiology. Nine different herbal medicines were tested in the included trials. The trials reported electrocardiogram results, level of myocardial enzymes, cardiac function, symptoms, and adverse effects.Astragalus membranaceus (either as an injection or granules) showed significant positive effects in symptom improvement, normalisation of electrocardiogram results, CPK levels, and cardiac function. Shengmai injection also showed significant effects in symptom improvement. Shengmai decoction triggered significant improvement in quality of life measured by SF-36. No serious adverse effects were reported.

AUTHORS' CONCLUSIONS

Some herbal medicines may lead to improvement of symptoms, ventricular premature beat, electrocardiogram, level of myocardial enzymes, and cardiac function in viral myocarditis. However, interpretation of these findings should be taken with care due to the low methodological quality, small sample size, and limited number of trials on individual herbs. Further robust trials are needed to explore the use of herbal medicines in viral myocarditis.

Mechanical circulatory support in the ICCU

The mortality of acute heart failure (AHF) remains high despite advances in treatment. Mechanical circulatory support (MCS) can be applied in AHF, refractory to conventional measures, to improve outcomes. This article aims to describe the current and the prospective role of MCS in the treatment of AHF. The support strategies and the indications of MCS are continuously evolving, including situations considered as contraindications in the past. Appropriate patient selection, advanced device technology and improved patient management have contributed to the substantially improved results. Evolution in device technology results in evolution of the clinical applications of MCS. Earlier application of MCS, with novel, flexible and individualized support strategies is now feasible. Bridging to recovery is the most intriguing support strategy and bridging to future treatments is feasible with long-term support. The progressively expanding role of MCS in the treatment of heart failure is not reflected in the existing guidelines. Being reserved for refractory heart failure, MCS has been applied to the sickest patients who were less amenable to randomization. This explains the lack of robust evidence, but also highlights the value of the progressively improving results. The anticipated wider application of MCS should be better defined, systematically recorded, and guided.

Myocarditis

Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms in children and adults. Viral infection is the most common cause of myocarditis in developed countries, but other etiologies include bacterial and protozoal infections, toxins, drug reactions, autoimmune diseases, giant cell myocarditis, and sarcoidosis. Acute injury leads to myocyte damage, which in turn activates the innate and humeral immune system, leading to severe inflammation. In most patients, the immune reaction is eventually down-regulated and the myocardium recovers. In select cases, however, persistent myocardial inflammation leads to ongoing myocyte damage and relentless symptomatic heart failure or even death. The diagnosis is usually made based on clinical presentation and noninvasive imaging findings. Most patients respond well to standard heart failure therapy, although in severe cases, mechanical circulatory support or heart transplantation is indicated. Prognosis in acute myocarditis is generally good except in patients with giant cell myocarditis. Persistent, chronic myocarditis usually has a progressive course but may respond to immunosuppression.

Pediatric patients hospitalized with myocarditis: a multi-institutional analysis

The objective of this study was to identify the patient, institutional, and utilization characteristics associated with outcome in hospitalized pediatric patients with myocarditis. This was a nonconcurrent cohort study of all consecutive pediatric discharges from the 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS): patients from birth through age 21 years discharged from participating hospitals between January 1, 2005, and December 31, 2005. Patient-level, institution-level, and utilization variables were examined. A total of 427,615 patients were discharged, and 216 (0.05%) were diagnosed with myocarditis. Common etiologies were idiopathic (82%), related to other diseases (6%), and bacterial or viral (3%). Myocarditis patients required considerable support including intravenous immunoglobulin (IVIG; 49.1%), milrinone (45%), epinephrine (35%), mechanical ventilation (25%), extracorporeal membrane oxygenation (7%), and cardiac transplantation (5%). Even in patients with extreme illness scores, IVIG use did not impact survival (P = 0.67). Overall survival of myocarditis patients was 92%. Myocarditis patients who died presented with a higher severity of illness and required frequent use of extracorporeal membrane oxygenation and other ICU therapies. In conclusion, pediatric patients with myocarditis have considerable variability in their presentations and outcomes, use more resources, and die more often than children with other diagnoses. Attempts at using characteristics that uniformly predict illness severity or survival were not successful. Despite increased use in the sickest patients, IVIG conferred no survival advantage.

[Assisted circulation: an overview from a clinical perspective]

A higher grade cardiac failure is associated with poor prognosis. In addition to medical conservative treatment and traditional cardiac surgery, in the past years different forms of an assisted circulation evolved. Short-term devices serve to bridge an acute life-threatening situation. The chosen system is dependent on the anticipated clinical course. It is possible to fall back on slightly assisting techniques up to a complete takeover of the cardiac pump function. In the case of severe cardiac failure, the question for transplantation has to be addressed because transplantation is the treatment of choice to date. For an assisted circulation in cases of chronic congestive failure, devices of different generations are available. First generation pulsatile systems are used for assistance of the left ventricle and results have been shown to be superior to medical therapy (REMATCH). With second generation continuous-flow systems, results regarding infections, thromboembolism and also quality of life appear to be further improved. Contact-free centrifugal pumps as third generation systems are in clinical evaluation. So-called "total artificial hearts" are successfully used for bridge-to-transplantation. Taken together, a graded safe treatment of cardiac failure is available today. In the near future, it could be possible to reach results similar to those of cardiac transplantation.

Myocarditis

Myocarditis may present with a wide range of symptoms, ranging from mild dyspnea or chest pain that resolves without specific therapy to cardiogenic shock and death. Dilated cardiomyopathy with chronic heart failure is the major long-term sequela of myocarditis. Most often, myocarditis results from common viral infections; less commonly, specific forms of myocarditis may result from other pathogens, toxic or hypersensitivity drug reactions, giant-cell myocarditis, or sarcoidosis. The prognosis and treatment of myocarditis vary according to the cause, and clinical and hemodynamic data usually provide guidance to decide when to refer a patient to a specialist for endomyocardial biopsy. The aim of this review is to provide a practical and current approach to the evaluation and treatment of suspected myocarditis.

Herbal medicines for viral myocarditis

BACKGROUND

Herbal medicines are being used for treating viral diseases including viral myocarditis, and many controlled trials have been done to investigate their efficacy.

OBJECTIVES

To assess the effects of herbal medicines on clinical and indirect outcomes in patients with viral myocarditis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library 2003, Issue 3, MEDLINE (January 1966 to October 2003), EMBASE (January 1998 to October 2003), Chinese Biomedical Database (1979-2003), AMED (1985-2003), LILACS accessed in October 2003 and the trials register of the Cochrane Complementary Medicine Field. We handsearched Chinese journals and conference proceedings. No language or publication restrictions were used.

SELECTION CRITERIA

Randomised controlled trials of herbal medicines (with a minimum of seven days treatment duration) compared with placebo, no intervention, or conventional interventions were included. Trials of herbal medicine plus conventional drug versus drug alone were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and evaluated trial quality. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Forty randomised trials, involving 3448 people were included. All trials were conducted and published in China, and the methodological quality was assessed as generally low. No trial had diagnosis of viral myocarditis confirmed histologically, and few trials attempted to establish viral aetiology for the myocarditis. Twenty-five different herbal medicines were tested in the included trials, which compared herbs with supportive therapy (17 trials), other controls (three trials), or treatment of herbs plus supportive therapy with supportive therapy alone (20 trials). The trials reported electrocardiogram, myocardial enzymes, cardiac function, symptoms, and adverse effects. Astragalus membranaceus (either as single herb or compound of herbs) showed significantly effects on improving arrhythmia, CPK levels, and cardiac function. Salviae miltiorrhizae injection showed significant effects on decreasing the arrhythmia and reducing LDH levels. Shenmai and Shengmai injection (Ginseng preparation) showed significantly effects on reducing myocardial enzymes and improving cardiac function. No serious adverse effect was reported.

REVIEWERS' CONCLUSIONS

Some herbal medicines may have anti-arrhythmia effect in suspected viral myocarditis. However, interpretation of these findings should be careful due to the low methodological quality, small sample size, and limited number of trials on individual herbs. In the light of the findings, some herbal medicines deserve further examination in rigorous trials.