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Lenz M, Krychtiuk KA, Zilberszac R, Heinz G, Riebandt J, Speidl WS. Mechanical Circulatory Support Systems in Fulminant Myocarditis: Recent Advances and Outlook. J Clin Med 2024; 13:1197. [PMID: 38592041 PMCID: PMC10932153 DOI: 10.3390/jcm13051197] [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: 02/10/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Max Lenz
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria (W.S.S.)
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Konstantin A. Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria (W.S.S.)
| | - Robert Zilberszac
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria (W.S.S.)
| | - Gottfried Heinz
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria (W.S.S.)
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Walter S. Speidl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria (W.S.S.)
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Stein AP, Stewart BD, Patel DC, Al-Ani M, Vilaro J, Aranda JM, Ahmed MM, Parker AM. Recurrent Cardiac Sarcoidosis and Giant Cell Myocarditis After Heart Transplant: A Case Report and Systematic Literature Review. Am J Cardiol 2023; 207:271-279. [PMID: 37769570 DOI: 10.1016/j.amjcard.2023.08.005] [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: 05/02/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 10/03/2023]
Abstract
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.
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Affiliation(s)
| | | | - Divya C Patel
- Division of Pulmonary, Critical Care and Sleep Medicine
| | - Mohammad Al-Ani
- Division of Cardiology, Department of Medicine, University of Florida Gainesville, Florida
| | - Juan Vilaro
- Division of Cardiology, Department of Medicine, University of Florida Gainesville, Florida
| | - Juan M Aranda
- Division of Cardiology, Department of Medicine, University of Florida Gainesville, Florida
| | - Mustafa M Ahmed
- Division of Cardiology, Department of Medicine, University of Florida Gainesville, Florida
| | - Alex M Parker
- Division of Cardiology, Department of Medicine, University of Florida Gainesville, Florida
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3
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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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Nakajima-Doi S, Mochizuki H, Iwasaki K, Kuroda K, Watanabe T, Tadokoro N, Okada A, Asaumi Y, Kanzaki H, Fukushima S, Seguchi O, Yanase M, Izumi C, Fujita T, Kobayashi J, Fukushima N. Mechanical Circulatory Support Combined With Immunosuppression for the Treatment of Giant Cell Myocarditis - A Single-Center Experience in Japan. Circ J 2020; 84:815-819. [PMID: 32173690 DOI: 10.1253/circj.cj-19-0847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Seiko Nakajima-Doi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Hiroki Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Keiichiro Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kensuke Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Naoki Tadokoro
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satsuki Fukushima
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tomoyuki Fujita
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Junjiro Kobayashi
- Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
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5
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Montero S, Aissaoui N, Tadié JM, Bizouarn P, Scherrer V, Persichini R, Delmas C, Rolle F, Besnier E, Le Guyader A, Combes A, Schmidt M. Fulminant giant-cell myocarditis on mechanical circulatory support: Management and outcomes of a French multicentre cohort. Int J Cardiol 2018; 253:105-112. [PMID: 29306448 DOI: 10.1016/j.ijcard.2017.10.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/04/2017] [Accepted: 10/13/2017] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Santiago Montero
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France; Acute and Intensive Cardiovascular Care Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Nadia Aissaoui
- Intensive Care Unit, U970, European Georges-Pompidou Hospital, Paris Descartes University, Paris, France
| | - Jean-Marc Tadié
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | - Vincent Scherrer
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Romain Persichini
- Medical-Surgical Intensive Care Unit, CHU de La Réunion, Felix-Guyon Hospital, Saint Denis, La Réunion, France
| | - Clément Delmas
- Medical Intensive Care Unit, Rangueil Hospital, Toulouse, France
| | - Florence Rolle
- Thoracic and Cardiac Surgery Department, CHU Limoges, Limoges, France
| | - Emmanuel Besnier
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | | | - Alain Combes
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.
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6
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Elamm CA, Al-Kindi SG, Bianco CM, Dhakal BP, Oliveira GH. Heart Transplantation in Giant Cell Myocarditis: Analysis of the United Network for Organ Sharing Registry. J Card Fail 2017; 23:566-569. [DOI: 10.1016/j.cardfail.2017.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/16/2017] [Accepted: 04/20/2017] [Indexed: 11/29/2022]
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7
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DeFilippis EM, Narain S, Sobol I, Narula N, Bass A, Erkan D. Rapidly Progressive Cardiac Failure Due to Giant Cell Myocarditis: A Clinical Pathology Conference Held by the Division of Rheumatology at Hospital for Special Surgery. HSS J 2015; 11:182-6. [PMID: 26140040 PMCID: PMC4481256 DOI: 10.1007/s11420-015-9449-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/23/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Ersilia M. DeFilippis
- />Weill Cornell Medical College, New York, NY 10065 USA
- />NewYork-Presbyterian Hospital, New York, NY 10065 USA
| | - Sonali Narain
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Irina Sobol
- />Weill Cornell Medical College, New York, NY 10065 USA
- />NewYork-Presbyterian Hospital, New York, NY 10065 USA
| | | | - Anne Bass
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Doruk Erkan
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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8
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Murray LK, González-Costello J, Jonas SN, Sims DB, Morrison KA, Colombo PC, Mancini DM, Restaino SW, Joye E, Horn E, Takayama H, Marboe CC, Naka Y, Jorde UP, Uriel N. Ventricular assist device support as a bridge to heart transplantation in patients with giant cell myocarditis. Eur J Heart Fail 2014; 14:312-8. [DOI: 10.1093/eurjhf/hfr174] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Evan Joye
- Medicine; Columbia University; New York NY10032 USA
| | - Evelyn Horn
- Medicine; Columbia University; New York NY10032 USA
| | | | - Charles C. Marboe
- Department of Pathology and Cell Biology; Columbia University; New York NY 10032 USA
| | | | | | - Nir Uriel
- Medicine; Columbia University; New York NY10032 USA
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9
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10
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Case of fulminant giant-cell myocarditis associated with polymyositis, treated with a biventricular assist device and subsequent heart transplantation. Heart Lung 2011; 40:340-5. [DOI: 10.1016/j.hrtlng.2010.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 05/22/2010] [Accepted: 06/01/2010] [Indexed: 11/19/2022]
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11
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 867] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Pauschinger M, Noutsias M, Lassner D, Schultheiss HP, Kuehl U. Inflammation, ECG changes and pericardial effusion: whom to biopsy in suspected myocarditis? Clin Res Cardiol 2006; 95:569-83. [PMID: 16897143 PMCID: PMC2780695 DOI: 10.1007/s00392-006-0427-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Accepted: 06/27/2006] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- M Pauschinger
- Medizinische Klinik II, Department of Cardiology and Pneumonology, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, 12200, Berlin, Germany.
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14
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Murashita T, Sugiki T, Tachibana T, Kunihara T, Sugiki H. A case of giant cell myocarditis: Bridge to recovery by long-term mechanical circulatory support without immunosuppressive therapy. J Thorac Cardiovasc Surg 2006; 132:432-3. [PMID: 16872979 DOI: 10.1016/j.jtcvs.2006.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2005] [Revised: 04/24/2006] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Toshifumi Murashita
- Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan.
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15
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Das BB, Recto M, Johnsrude C, Klein L, Orman K, Shoemaker L, Mitchell M, Austin EH. Cardiac Transplantation for Pediatric Giant Cell Myocarditis. J Heart Lung Transplant 2006; 25:474-8. [PMID: 16563980 DOI: 10.1016/j.healun.2005.11.444] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2005] [Revised: 11/03/2005] [Accepted: 11/10/2005] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Bibhuti B Das
- Division of Cardiology, Department of Pediatrics, University of Louisville, Louisville, Kentucky 40202, USA.
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16
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Moloney ED, Egan JJ, Kelly P, Wood AE, Cooper LT. Transplantation for myocarditis: a controversy revisited. J Heart Lung Transplant 2005; 24:1103-10. [PMID: 16102447 DOI: 10.1016/j.healun.2004.06.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2003] [Revised: 06/07/2004] [Accepted: 06/18/2004] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Edward D Moloney
- Department of Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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17
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Singh TP, Rabah R, Cooper LT, Walters HL. Total lymphoid irradiation: new therapeutic option for refractory giant cell myocarditis. J Heart Lung Transplant 2005; 23:492-5. [PMID: 15063411 DOI: 10.1016/s1053-2498(03)00214-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2003] [Revised: 04/24/2003] [Accepted: 04/24/2003] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Tajinder P Singh
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan, USA.
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18
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Stoica SC, Goddard M, Tsui S, Dunning J, McNeil K, Parameshwar J, Large SR. Ventricular assist surprise: giant cell myocarditis or sarcoidosis? J Thorac Cardiovasc Surg 2003; 126:2072-4. [PMID: 14688728 DOI: 10.1016/s0022-5223(03)00750-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S C Stoica
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
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19
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Abstract
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.
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Affiliation(s)
- Leslie T. Cooper
- Division of Cardiovascular Medicine. Department of Internal Medicine, The Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
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.
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Affiliation(s)
- A S Batra
- Division of Cardiology, Childrens Hospital Los Angeles and the University of Southern California Los Angeles, California 90027, USA
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