Early characteristics of fulminant myocarditis vs non-fulminant myocarditis: A meta-analysis

A fatal case of fulminant myocarditis after influenza infection with a rapidly progressive course: A case report

Myocarditis is an inflammation of the heart muscle. The most common cause of myocarditis is viral infections. clinical presentation of acute myocarditis is highly variable and varies from asymptomatic to fulminant heart failure or sudden death. Fulminant myocarditis is a severe form of myocarditis characterized by heart failure, arrhythmia, cardiogenic shock, and sudden cardiac arrest. Early diagnosis and proper treatment are essential for improved survival. We present a case of a 34-year-old woman who presented with viral symptoms for two days and then died suddenly.

Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

Ventricular fibrillation/ventricular tachycardia within 72 h of VA-ECMO: incidence, outcomes, risk factors, and management

AIMS

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important technique for the treatment of refractory cardiogenic shock and cardiac arrest; however, the early management of ventricular fibrillation/ventricular tachycardia (VF/VT), within 72 h of VA-ECMO, and its effects on patient prognosis remain unclear.

METHODS AND RESULTS

We retrospectively analysed patients at the First Affiliated Hospital of Nanjing Medical University who underwent VA-ECMO between January 2017 and March 2022. The patients were divided into two groups, VF/VT and nVF/VT, based on whether or not VF/VT occurred within 72 h after the initiation of VA-ECMO. We utilized logistic regression analysis to evaluate the independent risk factors for VF/VT in patients undergoing VA-ECMO and to ascertain whether the onset of VF/VT affected 28 day survival rate, length of intensive care unit stay, and/or other clinical prognostic factors. Subgroup analysis was performed for the VF/VT group to determine whether defibrillation affected prognosis. In the present study, 126 patients were included, 65.87% of whom were males (83/126), with a mean age of 46.89 ± 16.23, a 28 day survival rate of 57.14% (72/126), an incidence rate of VF/VT within 72 h of VA-ECMO initiation of 27.78% (35/126), and 80% of whom (28/35) received extracorporeal cardiopulmonary resuscitation. The incidence of VF/VT resulting from cardiac arrest at an early stage was significantly higher than that of refractory cardiogenic shock (80% vs. 20%; P = 0.022). The restricted cubic spline model revealed a U-shaped relationship between VF/VT incidence and initial heart rate (iHR), and multivariate logistic regression analysis showed that an iHR > 120 b.p.m. [odds ratio (OR) 6.117; 95% confidence interval (CI) 1.672-22.376; P = 0.006] and hyperlactataemia (OR 1.125; 95% CI 1.016-1.246; P = 0.023) within 1 h of VA-ECMO initiation were independent risk factors for the occurrence of VF/VT. VF/VT was not found to be associated with the 28 day survival of patients undergoing VA-ECMO support, nor did it affect other secondary endpoints. Defibrillation did not alter the overall prognosis in patients with VF/VT during VA-ECMO.

CONCLUSIONS

An iHR > 120 b.p.m. and hyperlactataemia were independent risk factors for the occurrence of VF/VT within 72 h of VA-ECMO initiation. The occurrence of VF/VT does not affect, nor does defibrillation in these patients improve the overall patient prognosis.

TRIAL REGISTRATION

ChiCTR1900026105.

Development and Validation of a Prediction Model on Adult Emergency Department Patients for Early Identification of Fulminant Myocarditis

OBJECTIVE

It is difficult to predict fulminant myocarditis at an early stage in the emergency department. The objective of this study was to construct and validate a simple prediction model for the early identification of fulminant myocarditis.

METHODS

A total of 61 patients with fulminant myocarditis and 160 patients with acute myocarditis were enrolled in the training and internal validation cohorts. LASSO regression and multivariate logistic regression were selected to develop the prediction model. The selection of the model was based on overall performance and simplicity. A nomogram based on the optimal model was built, and its clinical usefulness was evaluated by decision curve analysis. The predictive model was further validated in an external validation group.

RESULTS

The resulting prediction model was based on 4 factors: systolic blood pressure, troponin I, left ventricular ejection fraction, and ventricular wall motion abnormality. The Brier scores of the final model were 0.078 in the training data set and 0.061 in the internal testing data set, respectively. The C-indexes of the training data set and the testing data set were 0.952 and 0.968, respectively. Decision curve analysis showed that the nomogram model developed based on the 4 predictors above had a positive net benefit for predicting probability thresholds. In the external validation cohort, the model also showed good performance (Brier score=0.007, and C-index=0.989).

CONCLUSION

We developed and validated an early prediction model consisting of 4 clinical factors (systolic blood pressure, troponin I, left ventricular ejection fraction, and ventricular wall motion abnormality) to identify potential fulminant myocarditis patients in the emergency department.

Analyzing fulminant myocarditis research trends and characteristics using the follower-leading clustering algorithm (FLCA): A bibliometric study

BACKGROUND

Myocarditis can be classified into 2 categories: fulminant myocarditis (FM) and nonfulminant myocarditis. FM is the most severe type, characterized by its acute and explosive nature, posing a sudden and life-threatening risk with a high fatality rate. Limited research has been conducted on FM characteristics using cluster analysis. This study introduces the following-leading clustering algorithm (`) as a unique method and utilizes it to generate a dual map and timeline view of FM themes, aiming to gain a better understanding of FM.

METHODS

The metadata were obtained from the Web of Science (WoS) database using an advanced search strategy based on the topic (TS= (("Fulminant") AND ("Myocarditis"))). The analysis comprised 3 main components: descriptive analytics, which involved identifying the most influential entities using CJAL scores and analyzing publication trends, author collaborations using the FLCA algorithm, and generating a dual map and timeline view of FM themes using the FLCA algorithm. The visualizations included radar plots divided into 4 quadrants, stacked bar and line charts, network charts, chord diagrams, a dual map overlay, and a timeline view.

RESULTS

The findings reveal that the prominent entities in terms of countries, institutes, departments, and authors were the United States, Huazhong University of Science and Technology (China), Cardiology, and Enrico Ammirati from Italy. A dual map, based on the research category, was created to analyze the relationship between citing and cited articles. It showed that articles related to cells and clinical medicine/surgery were frequently cited by articles in the fields of general health/public/nursing and clinical medicine/surgery. Additionally, a visual timeline view was presented on Google Maps, showcasing the themes extracted from the top 100 cited articles. These visualizations were successfully and reliably generated using the FLCA algorithm, offering insights from various perspectives.

CONCLUSION

A new FLCA algorithm was utilized to examine bibliometric data from 1989 to 2022, specifically focusing on FM. The results of this analysis can serve as a valuable guide for researchers, offering insights into the thematic trends and characteristics of FM research development. This, in turn, can facilitate and promote future research endeavors in this field.

Characteristics of Electrocardiogram Findings in Fulminant Myocarditis

Fulminant myocarditis (FM) is an acute and severe form of myocarditis with rapid progression and poor clinical outcomes in the absence of acute or chronic coronary artery disease. Electrocardiogram (ECG) abnormalities can provide preliminary clues for diagnosis; however, there is a lack of systemic descriptions on ECG changes in FM populations. Thus, a retrospective analysis of 150 consecutive FM patients and 300 healthy controls was performed to determine the characteristic ECG findings in FM. All patients included had markedly abnormal ECG findings. Specifically, 83 (55.33%) patients had significantly lower voltage with remarkably decreased QRS amplitudes in all leads compared with healthy controls (p < 0.01), and 77 (51.33%) patients had a variety of arrhythmias with lethality ventricular tachycardia/ventricular fibrillation in 21 (14.00%) patients and third-degree atrioventricular block in 21 (14.00%) patients, whereas sinus tachycardia was only found in 43 (28.67%) patients with the median heart rate (HR; 88.00 bpm, IQR: 76.00-113.50) higher than that of controls (73.00 bpm, IQR: 68.00-80.00) (p = 0.000). Conduction and repolarization abnormalities were common in patients. A longer QTc interval (452.00 ms, IQR: 419.00-489.50) and QRS duration (94.00 ms, IQR: 84.00-119.00) were observed in patients compared to controls (QTc interval = 399.00 ms, IQR: 386.00-414.00; QRS duration = 90.00 ms, IQR: 86.00-98.00) (p < 0.05). Additionally, HR > 86.50 bpm, QTc > 431.50 ms, and RV5 + SV1 < 1.715 mV can be used to predict FM. Thus, marked and severe ECG abnormalities provide preliminary clues for the diagnosis of FM.

Incidence of Myocarditis Associated with Diphtheria, Tetanus, and Pertussis Vaccine: A Rare Case Series

Myocarditis induced by diphtheria–tetanus–pertussis (DTP) vaccination is extremely rare, accounting for only two cases thus far. Hence, to supplement knowledge regarding its pathogenesis and treatment, we reported two cases of myocarditis associated with DTP vaccination in adults.

Two patients (a 40-year-old female and a 43-year-old male) presented with mild symptoms and were hemodynamically stable. In both patients, the DTP vaccination was given 4 and 6 days before admission. Both patients had prolonged corrected QT interval (QTc), poor left ventricular function, and high troponin levels at admission. However, numerous ST segment depression was only noted in the first case. Bacteriology and virology study results were negative for any pathogen. No atherosclerotic lesions were observed by coronary angiography. Cardiac magnetic resonance imaging was only performed in the second case, which confirmed the diagnosis of myocarditis. Initial therapy was administered with a beta-blocker, angiotensin-converting enzyme inhibitor, and intravenous methylprednisolone. Nonetheless, in the first case, rapid clinical deterioration and sudden cardiac death occur within 3 days of hospitalization. Learn from the first case, a high-dose intravenous immunoglobulin (IVIG) treatment was initiated in the second case, which resulted in an improvement in left ventricular function and clinical symptoms, as well as a significant reduction in QTc interval and troponin levels.

Rapid diagnostic testing and early recognition of the fulminant course is mandatory, allowing clinicians to aggressively treat the patient with high-dose intravenous immune globulin, thus obtaining a better outcome.

Successful rescue of fulminant myocarditis with mechanical circulatory support and immunosuppression therapy: A case report

Myocarditis is challenging to diagnose because of its various clinical manifestations. Fulminant myocarditis (FM) is a severe type of myocarditis characterized by heart failure, malignant arrhythmia, cardiogenic shock, and cardiac arrest. Its early diagnosis and timely treatment are crucial for a positive long-term prognosis. Here we report a case of 42-year-old woman who presented with fever, chest pain, and cardiogenic shock. An initial examination showed increased myocardial enzyme levels and diffuse ST-segment elevation. Urgent coronary angiography excluded coronary artery stenosis. Echocardiography revealed decreased left ventricular systolic function. Cardiac magnetic resonance imaging revealed cardiomyocyte necrosis and interstitial inflammatory edema. The patient was diagnosed with FM and administered antiviral and anti-infective agents, glucocorticoid, immunoglobulin, and supported with temporary cardiac pacemaker and positive airway therapy, and treated with continuous renal replacement therapy. As her clinical condition deteriorated rapidly, we immediately started an intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation. She was discharged on day 15 and recovered normally during follow-up. The early initiation of mechanical circulatory support and immunosuppression are life-saving tools for the treatment of FM.

Research focus and theme trend on fulminant myocarditis: A bibliometric analysis

Aims

This study intends to explore the research focus and trends of fulminant myocarditis (FM) to have a better understanding of the topic.

Materials and methods

The data were downloaded from the Web of Science (WoS) database using the topic (TS) advanced search strategy. Many instruments were used to extract, analyze, and visualize the data, such as Microsoft Excel, HistCite Pro, GunnMap, BibExcel, and VOSviewer.

Results

From 1985 to 2022, 726 documents were indexed in the WoS. The United States and Columbia University were the most productive country and institutions. Keywords co-occurrence was carried out and four research themes were identified. In addition, the top three prolific authors, the first three highly cited authors, and the core authors of the author co-citation network were identified. The topics that they kept an eye on were analyzed, and the research areas of key authors were similar to the results of keyword co-occurrence. The hot topics of FM were related to the mechanical circulatory support, etiology, diagnosis, and the disease or therapy associated with FM.

Conclusion

This study carried out a systematic analysis of the documents related to FM from 1985 to 2022, which can provide a guideline for researchers to understand the theme trend to promote future research to be carried out.

Successful treatment of fulminant myocarditis with intra-aortic balloon pump counterpulsation combined with immunoglobulin and glucocorticoid in a young male adult

Background

Fulminant myocarditis (FM) is a serious non-specific inflammatory disease of the myocardium. FM tends to occur in adolescents and the course of the disease progresses rapidly. It is prone to cardiogenic shock (CGS) and multiple organ failure (MOF) with high mortality. We report a case of FM with CGS and MOF in a young male who was successfully treated with intra-aortic balloon pump counterpulsation (IABP) combined with intravenous immunoglobulin (IVIG) and glucocorticoid (GC).

Case summary

A 21-year-old previously healthy man presented with fever, headache, and chest tightness. He came to the hospital for emergency treatment. The laboratory data showed that the levels of serum cardiac troponin I (cTnI), N-terminal B-type natriuretic peptide (NT-proBNP), myocardial zymogram, and neutrophils increased. Echocardiography showed pericardial effusion and decreased left ventricular systolic function. ECG showed diffuse ST-segment elevation. He was clinically diagnosed with FM and admitted to the intensive care unit for treatment. Within 48 h of admission, the clinical course of the patient deteriorated rapidly, with CGS accompanied by MOF, high atrioventricular block (AVB), and ventricular tachycardia (VT). After using mechanical circulatory support (MCS) therapy with IABP, IVIG, GC, continuous renal replacement therapy (CRRT), and mechanical ventilation complicated with a temporary cardiac pacemaker, he recovered normal cardiac function. He made a full recovery and was discharged home on day 21.

Discussion

For patients with FM, early diagnosis, close monitoring, timely use of MCS devices, and active comprehensive treatment are very important. MCS devices such as IABP can become lifesaving tools for the treatment of FM.

COVID-19 and myocarditis: a review of literature

Myocarditis has been discovered to be a significant complication of coronavirus disease 2019 (COVID-19), a condition caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. COVID-19 myocarditis seems to have distinct inflammatory characteristics, which make it unique to other viral etiologies. The incidence of COVID-19 myocarditis is still not clear as a wide range of figures have been quoted in the literature; however, it seems that the risk of developing myocarditis increases with more severe infection. Furthermore, the administration of the mRNA COVID-19 vaccine has been associated with the development of myocarditis, particularly after the second dose. COVID-19 myocarditis has a wide variety of presentations, ranging from dyspnea and chest pain to acute heart failure and possibly death. It is important to catch any cases of myocarditis, particularly those presenting with fulminant myocarditis which can be characterized by signs of heart failure and arrythmias. Initial work up for suspected myocarditis should include serial troponins and electrocardiograms. If myocardial damage is detected in these tests, further screening should be carried out. Cardiac magnetic resonance imagining and endomyocardial biopsy are the most useful tests for myocarditis. Treatment for COVID-19 myocarditis is still controversial; however, the use of intravenous immunoglobulins and corticosteroids in combination may be effective, particularly in cases of fulminant myocarditis. Overall, the incidence of COVID-19 myocarditis requires further research, while the use of intravenous immunoglobulins and corticosteroids in conjunction requires large randomized controlled trials to determine their efficacy.

Symptomatic Young Adults with ST-Segment Elevation-Acute Coronary Syndrome or Myocarditis: The Three-Factor Diagnostic Model

Myocarditis may mimic myocardial infarction (MI) due to a similar clinical presentation, including chest pain, electrocardiography changes, and laboratory findings. The purpose of the study was to investigate the diagnostic value of clinical, laboratory, and electrocardiography characteristics of patients with acute coronary syndrome - like myocarditis and MI. We analysed 90 patients (≤45 years old) with an initial diagnosis of ST-segment elevation myocardial infarction; 40 patients (44.4%), through the use of cardiac magnetic resonance, were confirmed to have myocarditis, and 50 patients (55.6%) were diagnosed with MI. Patients with myocarditis were younger and had fewer cardiovascular risk factors than those with MI. The cutoff value distinguishing between myocarditis and MI was defined as the age of 36 years. The history of recent infections (82.5% vs. 6%) and C-reactive protein (CRP) levels on admission (Me 45.9 vs. 3.4) was more associated with myocarditis. Further, the QTc interval was inversely correlated with the echocardiographic ejection fraction in both groups but was significantly longer in patients with MI. Non-invasive diagnostics based on clinical features and laboratory findings are basic but still essential tools for differentiation between MI and myocarditis. The three-factor model including the criteria of age, abnormal CRP, and history of recent infections might become a valuable clinical indication.

Myocardial infarction or acute coronary syndrome with non-obstructive coronary arteries and sudden cardiac death: a missing connection

Myocardial infarction with non-obstructive coronary arteries or any acute coronary syndrome (ACS) with normal or near-normal (non-obstructive) coronary arteries (ACS-NNOCA) is an heterogeneous clinical entity, which includes different pathophysiology mechanisms and is challenging to treat. Sudden cardiac death (SCD) is a catastrophic manifestation of ACS that is crucial to prevent and treat urgently. The concurrence of the two conditions has not been adequately studied. This narrative review focuses on the existing literature concerning ACS-NNOCA pathophysiology, with an emphasis on SCD, together with risk and outcome data from clinical trials. There have been no large-scale studies to investigate the incidence of SCD within ACS-NNOCA patients, both early and late in the disease. Some pathophysiology mechanisms that are known to mediate ACS-NNOCA, such as atheromatous plaque erosion, anomalous coronary arteries, and spontaneous coronary artery dissection are documented causes of SCD. Myocardial ischaemia, inflammation, and fibrosis are probably at the core of the SCD risk in these patients. Effective treatments to reduce the relevant risk are still under research. ACS-NNOCA is generally considered as an ACS with more 'benign' outcome compared to ACS with obstructive coronary artery disease, but its relationship with SCD remains obscure, especially until its incidence and effective treatment are evaluated.

Diagnosis and Management of Myocarditis: An Evidence-Based Review for the Emergency Medicine Clinician

BACKGROUND

Myocarditis is a potentially fatal condition that can be misdiagnosed in the emergency department (ED) setting.

OBJECTIVE

The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of myocarditis, with a focus on emergency clinicians.

DISCUSSION

Myocarditis occurs when inflammation of the heart musculature causes cardiac dysfunction. Symptoms may range from mild to severe and are often preceded by a viral prodrome. Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is the ideal test in the ED setting. Some patients may also require advanced imaging, though this will often occur during hospitalization or follow-up. Treatment is primarily focused on respiratory and hemodynamic support. Initial hemodynamic management includes vasopressors and inotropes, whereas more severe cases may require an intra-aortic balloon pump, extracorporeal membrane oxygenation, or a ventricular assist device. Nonsteroidal anti-inflammatory drugs should be avoided while intravenous immunoglobulin is controversial.

CONCLUSION

Myocarditis is a serious condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

The use of extracorporeal membrane oxygenation in the treatment of fulminant myocarditis: Current progress and clinical outcomes

Myocarditis is an inflammatory condition of the myocardium and is usually categorised as acute nonfulminant and acute fulminant myocarditis. Myocardial injury can result via viral infections, direct injury or immune responses. Fulminant myocarditis can be characterised by severe and sudden cardiac inflammation that may result from cardiogenic shock, ventricular arrhythmias or multi-organ system failure. Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is an effective technique for patients with fulminant myocarditis, providing heart and lung support and adequate gas exchange or perfusion to sustain life. Essentially, ECMO pumps blood out of the body to an oxygenator that acts as an artificial lung, which adds oxygen to the blood and removes carbon dioxide. This report aims to review recent advances in ECMO and relate case studies of fulminant myocarditis patients. The types of ECMO, predictive factors for success, clinical studies and recent technological advances in the field will be discussed.

The Possible Role of IVIG in the Treatment of Atrial Fibrillation Accompanied by Fulminant Myocarditis in a 12-Year-Old Pediatric Patient

Background

Fulminant myocarditis (FM) is a potentially lethal condition in children due to rapid progressive hemodynamic instability and cardiogenic shock. Patients with FM might show different clinical manifestations on emergency department admission.

Case

Herein, we describe the case of a 12-year-old girl who was admitted to our institution's emergency department due to complaints of abdominal pain and incessant vomiting. However, we detected an early onset of atrial fibrillation (AF) accompanied by FM. The patient's condition of AF and severe hemodynamic disorder was successfully treated in our institution's pediatric intensive care unit.

Conclusion

To the best of our knowledge, this is the first report of the co-occurrence of FM and AF successfully treated in childhood. This case report will serve as a guide for the treatment of cases with FM accompanied by AF.

Establishment and assessment of a nomogram model for predicting the risk of fulminant myocarditis: A STROBE compliant cross-sectional study

ABSTRACT

We aimed to identify potential clinical predictors associated with the risk of fulminant myocarditis, and further to establish and assess a nomogram model based on significant attributes for clinical practicability.This is a retrospective, cross-sectional study, involving 28 patients with fulminant myocarditis and 35 age-, and sex-matched patients with non-fulminant myocarditis. Effect-size estimates are expressed as odds ratio (OR) and 95% confidence interval (CI).Fifteen factors were primarily identified to be associated with the significant risk of fulminant myocarditis after adjusting for confounders. Due to strong correlation, 6 factors were retained, including mean arterial pressure (OR, 95% CI, P: .82, .72-.94, .005), creatinine (2.15, 1.13-4.10, 0.020), blood urea nitrogen (1.45, 1.04-2.02, 0.028), aspartate aminotransferase (2.62, 1.16-5.91, 0.021), troponin I (1.43, 1.07-1.90, 0.015), and ventricular wall motion abnormality (25.81, 2.52-264.69, 0.006). The contribution of the 6 significant factors to predicting fulminant myocarditis risk was significant from multi-angle analyses, and regressing these factors in a nomogram model exhibited good predictive accuracy, as reflected by both C-index (>90%, P < .001).We have identified 6 clinical factors in significant association with fulminant myocarditis, and their prediction capability was more obvious in a nomogram model. Further investigations with larger sample sizes and longer follow-up intervals are warranted.

A mini-thoracotomy approach for walking veno-arterial extracorporeal membranous oxygenation

Fulminant myocarditis is a rapidly progressive myocardial inflammation that commonly requires advanced circulatory support therapies. We report our management of a 36-year-old gentleman with fulminant myocarditis who we managed with extracorporeal membranous oxygenation (ECMO) and subsequently durable bi-ventricular assist devices as a bridge to heart transplantation. The patient was admitted after a 1-week history of malaise with severe lethargy, jugular venous distension to greater than 10 cm, and troponin elevation to greater than 27 K. He was taken immediately for a heart catheterization which showed no obstructive coronary disease, and hemodynamics consistent with bi-ventricular failure. We proceeded with ECMO for hemodynamic support, utilizing a mini-thoracotomy for cannulation. A Protek Duo Rapid Deployment (LivaNova) was inserted via a modified Seldinger technique through the left ventricular apex, terminating in the ascending aorta. Percutaneous right IJ bicaval via a y-ed Avalon Elite (Getinge) was employed for venous drainage. This case highlights an alternate strategy for central walking veno-arterial ECMO in a patient presenting with fulminant myocarditis with a platform that minimizes upper/lower extremity over/under perfusion complications, while providing sternal sparring antegrade arterial flow with simultaneous ventricular unloading/venting.

Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes

Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.

The diagnostic capability of electrocardiography on the cardiogenic shock in the patients with acute myocarditis

Background

The study was performed to assess the diagnostic capability of ECG on the cardiogenic shock (CS) in acute myocarditis. A new score was derived from the combination of the ECG parameters and the diagnostic value was also evaluated.

Methods

Total 103 consecutive patients with acute myocarditis admitted in Nanjing Drum Hospital were enrolled in the current study. The cohort was divided into fulminant myocarditis group (FM, n = 20) and non fulminant myocarditis group (NFM, n = 83). The demographic features, results of electrocardiography (ECG) and ultracardiography were compared. Logistic regression analysis was conducted to identify the relevant factors in ECG parameters. We created a new variable called “ECG score” by certain combination of ECG parameters. The diagnostic capability of ECG score for CS was compared with the existing diagnostic indices using regression model and receiver-operating characteristics (ROC) analysis.

Results

There were several changes on ECG significantly different between the two groups. Multivariate regression analysis demonstrated PR + QRS interval (P = 0.008), ventricular arrhythmia (P = 0.001) and pathological Q wave (P = 0.003) were the independent relevant factors of CS. The derived variable “ECG score” was identified as a significant relevant factor of CS by multivariate regression model. ROC analysis showed PR + QRS interval, ventricular arrhythmia and pathological Q wave all had equivalent diagnostic capability to left ventricular ejection fraction (LVEF) and shock index (SI). ECG score was equivalent to LVEF but superior to SI in diagnosing CS

Conclusions

ECG was valuable in diagnosing CS due to acute myocarditis. The ECG score was superior to the traditional diagnostic indices and could be used for an rapid recognition of CS.

Risk factors for adverse cardiac events in adults with fulminant myocarditis during hospitalization

BACKGROUND

Fulminant myocarditis is the critical form of myocarditis that is often associated with heart failure, malignant arrhythmia, and circulatory failure. Patients with fulminant myocarditis who end up with severe multiple organic failure and death are not rare.

AIM

To analyze the predictors of in-hospital major adverse cardiovascular events (MACE) in patients diagnosed with fulminant myocarditis.

METHODS

We included a cohort of adult patients diagnosed with fulminant myocarditis who were admitted to Beijing Anzhen Hospital from January 2007 to December 2017. The primary endpoint was defined as in-hospital MACE, including death, cardiac arrest, cardiac shock, and ventricular fibrillation. Baseline demographics, clinical history, characteristics of electrocardiograph and ultrasonic cardiogram, laboratory examination, and treatment were recorded. Multivariable logistic regression was used to examine risk factors for in-hospital MACE, and the variables were subsequently assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

The rate of in-hospital MACE was 40%. Multivariable logistic regression analysis revealed that baseline QRS duration > 120 ms was the independent risk factor for in-hospital MACE (odds ratio = 4.57, 95%CI: 1.23-16.94, P = 0.023). The AUC of QRS duration > 120 ms for predicting in-hospital MACE was 0.683 (95%CI: 0.532-0.833, P = 0.03).

CONCLUSION

Patients with fulminant myocarditis has a poor outcome. Baseline QRS duration is the independent risk factor for poor outcome in those patients.

Hypoperfusion With Vomiting, Abdominal Pain, or Dizziness and Convulsions: An Alert to Fulminant Myocarditis in Children

Objective: To investigate the clinical features, treatment methods, and outcomes of fulminant myocarditis (FM) in children. Methods: The clinical data of 23 children with FM hospitalized in the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Hospital) and Anhui Provincial Children's Hospital from January 2011 to September 2019 were retrospectively analyzed. Results: Among the 23 patients analyzed, 10 were male and 13 were female. The patients aged from 6 months to 14 years old (6.5 ± 3.4 years), and 18 patients were over 3 years old. There were 14 cases with respiratory symptoms, 16 cases with gastrointestinal symptoms, 15 cases with neurological symptoms, and 19 cases with hypoperfusion manifestations. Creatine kinase MB (CK-MB) and cardiac troponin I (CTnI) levels were increased in 19 and 21 cases, respectively. Electrocardiography (ECG) showed ST-T changes in 18 cases and atrioventricular blocks (AVB) in 15 cases. Echocardiography (ECHO) showed cardiac chamber enlargement (CCE) in eight cases, left ventricular systolic dysfunction in five cases, decrease in left ventricular ejection fraction (LVEF) in four cases, reduction in wall motion in two cases, and pericardial effusion in seven cases. Intravenous immunoglobulin (IVIG) and glucocorticoids were administered to 19 and 20 patients, respectively. Fourteen patients were treated with temporary pacemakers, one patient received extracorporeal membrane oxygenation (ECMO), one patient received continuous renal replacement therapy (CRRT), and one patient received ECMO combined with CRRT. Twenty patients improved at discharge, and three patients died. Conclusion: Preschool and school-age children showing hypoperfusion symptoms, such as paleness, cold, clammy limbs, and capillary refill time (CRT) extension, accompanied by vomiting, abdominal pain, dizziness, convulsions, and other symptoms, should be carefully examined for FM. CK-MB, CTnI, ECG, and echocardiogram need to be performed at the earliest opportunity. In the early stages of FM, vital signs should be actively monitored, high-dose IVIG and glucocorticoids should be administered, and life support technologies such as temporary pacemakers, ECMO, and CRRT should be used to increase the survival rate of children with FM as needed.

Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review

Background

Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non‐specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis.

Methods

We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield.

Results

The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T‐wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high‐degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis.

Conclusions

ECG alterations in acute myocarditis could be very useful in clinical practice for a patient‐tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.