Survival outcomes of patients with giant cell myocarditis bridged by ventricular assist devices

Mechanical Circulatory Support Systems in Fulminant Myocarditis: Recent Advances and Outlook

Background: Fulminant myocarditis (FM) constitutes a severe and life-threatening form of acute cardiac injury associated with cardiogenic shock. The condition is characterised by rapidly progressing myocardial inflammation, leading to significant impairment of cardiac function. Due to the acute and severe nature of the disease, affected patients require urgent medical attention to mitigate adverse outcomes. Besides symptom-oriented treatment in specialised intensive care units (ICUs), the necessity for temporary mechanical cardiac support (MCS) may arise. Numerous patients depend on these treatment methods as a bridge to recovery or heart transplantation, while, in certain situations, permanent MCS systems can also be utilised as a long-term treatment option. Methods: This review consolidates the existing evidence concerning the currently available MCS options. Notably, data on venoarterial extracorporeal membrane oxygenation (VA-ECMO), microaxial flow pump, and ventricular assist device (VAD) implantation are highlighted within the landscape of FM. Results: Indications for the use of MCS, strategies for ventricular unloading, and suggested weaning approaches are assessed and systematically reviewed. Conclusions: Besides general recommendations, emphasis is put on the differences in underlying pathomechanisms in FM. Focusing on specific aetiologies, such as lymphocytic-, giant cell-, eosinophilic-, and COVID-19-associated myocarditis, this review delineates the indications and efficacy of MCS strategies in this context.

Recurrent Cardiac Sarcoidosis and Giant Cell Myocarditis After Heart Transplant: A Case Report and Systematic Literature Review

Recurrence of cardiac sarcoidosis (CS) and giant cell myocarditis (GCM) after heart transplant is rare, with rates of 5% in CS and 8% in GCM. We aim to identify all reported cases of recurrence in the literature and to assess clinical course, treatments, and outcomes to improve understanding of the conditions. A systematic review, utilizing Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, was conducted by searching MEDLINE/PubMed and Embase of all available literature describing post-transplant recurrent granulomatous myocarditis, CS, or GCM. Data on demographics, transplant, recurrence, management, and outcomes data were collected from each publication. Comparison between the 2 groups were made using standard statistical approaches. Post-transplant GM recurrence was identified in 39 patients in 33 total publications. Reported cases included 24 GCM, 12 CS, and 3 suspected cases. Case reports were the most frequent form of publication. Mean age of patients experiencing recurrence was 42 years for GCM and 48 years for CS and favored males (62%). Time to recurrence ranged from 2 weeks to 9 years post-transplant, occurring earlier in GCM (mean 1.8 vs 3.0 years). Endomyocardial biopsies (89%) were the most utilized diagnostic method over cardiac magnetic resonance and positron emission tomography. Recurrence treatment regimens involved only steroids in 40% of CS, whereas other immunomodulatory regimens were utilized in 70% of GCM. In conclusion, GCM and CS recurrence after cardiac transplantation holds associated risks including concurrent acute cellular rejection, a higher therapeutic demand for GCM recurrence compared with CS, and mortality. New noninvasive screening techniques may help modify post-transplant monitoring regimens to increase both early detection and treatment of recurrence.

Management of Patients With Giant Cell Myocarditis: JACC Review Topic of the Week

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.

Mechanical Circulatory Support Combined With Immunosuppression for the Treatment of Giant Cell Myocarditis - A Single-Center Experience in Japan

BACKGROUND

The therapeutic strategy for giant cell myocarditis (GCM) remains controversial, so we reviewed the clinical status of Japanese patients with GCM.Methods and Results:We retrospectively reviewed 6 consecutive patients with GCM requiring percutaneous mechanical circulatory support (p-MCS), with 3 further requiring ventricular assist devices. One patient died during p-MCS. Cardiac function improved in the other 5 with immunosuppressive therapy, but only 3 patients treated with dual immunosuppressants, including cyclosporine (CyA), achieved >1-year survival.

CONCLUSIONS

The prognosis of patients with fulminant GCM is poor, but a treatment that combines MCS and early administration of CyA-based immunosuppressants will be useful.

Fulminant giant-cell myocarditis on mechanical circulatory support: Management and outcomes of a French multicentre cohort

AIMS

Giant-cell myocarditis (GCM) is a rare and often fatal form of myocarditis. Only a few reports have focused on fulminant forms. We describe the clinical characteristics, management and outcomes of GCM patients rescued by mechanical circulatory support (MCS).

METHODS AND RESULTS

The clinical features, diagnoses, treatments and outcomes of MCS-treated patients in refractory cardiogenic shock secondary to fulminant GCM admitted to eight French intensive care units (2002-2016) were analysed. We also conducted a systematic review of this topic. Thirteen patients (median age 44 [range 21-76]years, Simplified Acute Physiology Score II 55 [40-79]) in severe cardiogenic shock (median [range] left ventricular ejection fraction 15% [15-35%] and blood lactate 4 mmol/L) were placed on MCS 4 [0-28]days after hospital admission. Severe arrhythmic disturbances were frequent (77%), with six (46%) patients experiencing an electrical storm prior to MCS. Venoarterial extracorporeal membrane oxygenation was the first MCS option for 11 (85%) patients. GCM was diagnosed in five (38%) patients before transplant or death and treated with immunosuppressants; infections were the main complication (80%). Four patients died on MCS and no patient presented long-term survival free from heart transplant (nine patients, 69%). All transplanted patients were alive 1year later and no GCM recurrence was reported after median follow-up of 42 [12-145]months.

CONCLUSION

Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option.

Inflammation, ECG changes and pericardial effusion: whom to biopsy in suspected myocarditis?

The role of endomyocardial biopsies in patients with clinically suspected acute myocarditis, myocarditis in the past, and dilated cardiomyopathy is discussed controversially. In fact, it is still under discussion whether information obtained from endomyocardial biopsies is relevant for further clinical decisions. Therefore this Critical Perspective will deal with the question, which patient should undergo endomyocardial biopsy investigations for an etiopathogenic differentiation of the disease and for the possible choice of immunomodulatory treatment strategies.

Cardiac Transplantation for Pediatric Giant Cell Myocarditis

Giant cell myocarditis (GCM) is an organ-specific, autoimmune disease that infrequently affects children and generally has a more aggressive (often fatal) course than other forms of myocarditis. No data are available about the epidemiology of GCM in children. We describe a 13-year-old girl who presented with ventricular tachycardia and rapid hemodynamic deterioration that required extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplantation. Histopathologic examination of the explanted heart revealed GCM. We review the demographic features, clinical course and post-transplant immunosuppressive therapy of all patients aged 19 years and younger reported to have had GCM.

Transplantation for myocarditis: a controversy revisited

Myocarditis is a major cause of end-stage heart failure and is responsible for up to 10% of cases of idiopathic dilated cardiomyopathy (IDC). Worldwide, approximately 45% of all heart transplants are performed for IDC and up to 8% for myocarditis. Early reports suggested that survival after transplantation for myocarditis was poor and patients had an increased risk of rejection. More recently, larger case series suggest that overall survival after transplantation for myocarditis is similar to survival after transplantation for other causes. However, certain disorders, including cardiac sarcoidosis and giant cell myocarditis (GCM), require heightened surveillance for post-transplantation disease recurrence. We present the case of a 42-year-old man with recurrence of GCM 8 years after transplantation and review the literature on the role of cardiac transplantation for patients with myocarditis.

Total lymphoid irradiation: new therapeutic option for refractory giant cell myocarditis

Idiopathic giant cell myocarditis (GCM) is believed to be a T-lymphocyte-mediated autoimmune disease. Some patients with GCM have a dramatic clinical response to anti-T-cell immunosuppression. However, this response is not uniform and patients often deteriorate rapidly and need a cardiac transplantation within months of diagnosis. Following cardiac transplantation, GCM may recur in the graft but is usually mild and responds to augmentation of immunosuppression. This report is the first description of total lymphoid irradiation (TLI) for the treatment of GCM, which was used in a patient who developed an exceptionally early and severe recurrence of GCM in the cardiac graft that remained refractory to heightened immunosuppression for 4 months. Clinical and histologic remission followed a course of TLI and was maintained for 1 year despite a gradual decrease in immunosuppression. This novel treatment should be considered in all patients with GCM who do not have histologic remission with the currently employed anti-T-cell immunosuppression.

Idiopathic Giant Cell Myocarditis

Idiopathic giant cell myocarditis (IGCM) is an uncommon disorder that is of general importance because it most commonly affects young individuals, is usually fatal without treatment, and may respond to aggressive medical and surgical therapy. IGCM is most often progressive over days to weeks and frequently requires the concurrent management of congestive heart failure, tachyarrhythmias, and heart block. After common causes of heart disease are excluded, the diagnosis must be confirmed by endomyocardial biopsy. Standard pharmacologic therapy for New York Heart Association functional class II to III congestive heart failure due to left ventricular systolic failure includes an angiotensin-converting enzyme inhibitor, a beta-blocker such as carvedilol, and diuretics as needed. We avoid digoxin and reserve inotropic agents for patients whose circulatory requirements cannot be supported with standard oral vasodilators and diuretics. Heart block may require a temporary or permanent pacemaker. Ventricular tachycardia is common and usually is managed chronically with an implantable cardiac defibrillator and antiarrhythmic drugs such as amiodarone. Despite optimal medical management, mechanical support may be required as a temporary bridge to recovery or transplantation. The intra-aortic balloon pump and ventricular assist device have been used successfully for patients with refractory pump failure due to acute IGCM. Heart transplantation is efficacious, with a 71% 5-year survival, despite a 20% to 25% rate of histologic recurrence in surveillance endomyocardial biopsies. The role of aggressive immunosuppression as part of the primary treatment of IGCM is under active investigation. Preliminary data suggest that primary therapy with a regimen that includes muromonab-CD3, cyclosporine, and steroids may significantly improve transplant-free survival.

Acute myocarditis

Myocarditis is defined as inflammation of the myocardium accompanied by myocellular necrosis. Acute myocarditis must be considered in patients who present with recent onset of cardiac failure or arrhythmia. Often there is a history of an antecedent flu-like illness. Fulminant myocarditis is a distinct entity characterized by sudden onset of severe congestive heart failure or cardiogenic shock, usually following a flu-like illness. Giant cell myocarditis is a rare, frequently fatal disorder of unknown origin characterized by presence of giant cell inflammatory infiltrate in the myocardium. In recent years we have made good progress in understanding the causes, pathogenesis, natural history, diagnosis, and treatment of myocarditis. However, our knowledge is still far from complete. New information that extends our understanding of myocarditis is being reported constantly. This review summarizes recent advances in myocarditis, with an emphasis on the literature during the last year.