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Yao Y, Bian W, Zhang H, Ji X, Wang Z. Quantitative cardiac MRI parameters for assessment of myocarditis in children and adolescents: a systematic review and meta-analysis. Clin Radiol 2023:S0009-9260(23)00230-1. [PMID: 37365114 DOI: 10.1016/j.crad.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
AIM To evaluate the role of quantitative cardiac magnetic resonance imaging (CMRI) parameters in myocarditis, including acute and chronic myocarditis (AM and CM), for children and adolescents. MATERIALS AND METHODS PRISMA principles were followed. PubMed, EMBASE, Web of Science, Cochrane Library, and grey literature were searched. The Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) checklist were utilised for quality assessment. Quantitative CMRI parameters were extracted and a meta-analysis was performed in comparison with healthy controls. The overall effect size was measured as the weighted mean difference (WMD). RESULTS Ten quantitative CMRI parameters of seven studies were analysed. Compared with the control group, the myocarditis group reported longer native T1 relaxation time (WMD=54.00, 95% confidence interval [CI]: 33.21,74.79, p<0.001), longer T2 relaxation time (WMD=2.13, 95% CI: 0.98, 3.28, p<0.001), increased extracellular volume (ECV; WMD=3.13, 95% CI: 1.34,4.91, p=0.001), elevated early gadolinium enhancement (EGE) ratio (WMD=1.47, 95% CI: 0.65,2.28, p<0.001), and increased T2-weighted ratio (WMD=0.43, 95% CI: 0.21,0.64, p<0.001). The AM group had longer native T1 relaxation times (WMD=72.02, 95% CI: 32.78,111.27, p<0.001), increased T2-weighted ratios (WMD=0.52, 95% CI: 0.21,0.84 p=0.001), and impaired left ventricular ejection fractions (LVEF; WMD=-5.84, 95% CI: -9.69, -1.99, p=0.003). Impaired LVEF (WMD=-2.24, 95% CI: -3.32, -1.17, p<0.001) was observed in the CM group. CONCLUSION Statistical differences can be observed in some CMRI parameters between patients with myocarditis and healthy controls; however, apart from native T1 mapping, there were no large differences in other parameters between two groups, which may reveal the limited benefit of CMRI in assessing myocarditis in children and adolescents.
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Affiliation(s)
- Y Yao
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - W Bian
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - H Zhang
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - X Ji
- Department of Pediatrics, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China.
| | - Z Wang
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
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Singh K, Lutfi R, Parent JJ, Rogerson C, Yabrodi M. Recent Trends in Incidence and Outcomes for Acute Myocarditis in Children in the United States. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1762910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
AbstractLack of defined diagnostic criteria for acute myocarditis makes its diagnosis dependent on clinical suspicion. The objective of this study was to the current trends in demographics, clinical manifestations, treatments, and outcomes in the United States for children hospitalized with acute myocarditis. This retrospective study was conducted using data collected from the Pediatric Health Information System database for the years 2014 to 2020. We included patients 21 years of age or younger with acute myocarditis. The statistical analysis was performed using chi-squared test and continuous variables using Mann–Whitney's U-test for continuous data comparisons. We found 1,199 patients with acute myocarditis. About 60% of patients required admission to the intensive care unit (ICU). The median hospital length of stay was 4 days for all patients and 6 days for ICU patients. Two hundred sixty-five (22.1%) patients required invasive mechanical ventilation, 127 (10.6%) required extracorporeal membrane oxygenation, 33 (2.8%) required ventricular assist device, and 22 (1.8%) required cardiac transplantations. Milrinone was the most used vasoactive agent. The overall hospital mortality was 2.3%. Intravenous immunoglobulin (IVIG) infusion use decreased during the study period. On multivariate analysis, vasoactive medication use (p < 0.01) and arrhythmia (p = 0.02) were independently associated with increased odds of mortality. IVIG use (p = 0.01) was associated with decreased odds of mortality. Despite high morbidity and frequent need for advanced life support measures, the survival outcomes of acute myocarditis in children are favorable. Vasoactive medication support and occurrence of arrythmia were independently associated with mortality, most likely due to disease severity. Administration of IVIG was independently associated with reduced mortality. The Clinical trial registration is not applicable.
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Affiliation(s)
- Kalpana Singh
- Heart Center ICU, Children's Heart Institute, Children's Memorial Hermann Hospital, Houston, Texas, United States
- University of Texas, Houston, Texas, United States
| | - Riad Lutfi
- Division of Critical Care Medicine, Riley Hospital for Children, Indianapolis, Indiana, United States
- Indiana University, Indianapolis, Indiana, United States
| | - John J. Parent
- Division of Critical Care Medicine, Riley Hospital for Children, Indianapolis, Indiana, United States
- Indiana University, Indianapolis, Indiana, United States
| | - Colin Rogerson
- Division of Critical Care Medicine, Riley Hospital for Children, Indianapolis, Indiana, United States
- Indiana University, Indianapolis, Indiana, United States
| | - Mouhammad Yabrodi
- Division of Critical Care Medicine, Riley Hospital for Children, Indianapolis, Indiana, United States
- Indiana University, Indianapolis, Indiana, United States
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Extracorporeal Membrane Oxygenation Cannulation Timing in the Pediatric Myocarditis Population: An Exploratory Analysis From the Extracorporeal Life Support Organization Registry. Crit Care Explor 2022; 5:e0826. [PMID: 36619364 PMCID: PMC9810122 DOI: 10.1097/cce.0000000000000826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient population. DESIGN Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation. SETTING AND SUBJECTS The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Population characteristics and survival were compared using t test, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007-2012 vs 2013-2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3 hr [interquartile range (IQR)], 1-14 hr vs 6 hr [IQR, 2-20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02-0.40; p = 0.002) for ITC time greater than or equal to 18 hours. CONCLUSIONS The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.
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Albuali WH, Al-Qahtani MH, Yousef AA, Al Ghamdi MA, AlQurashi FO, Lardhi AA. Myocarditis in Children: Impact of Early Presentation on Disease Outcomes at a Single Tertiary Center in Saudi Arabia. Int J Gen Med 2022; 15:5627-5633. [PMID: 35726274 PMCID: PMC9206454 DOI: 10.2147/ijgm.s369088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Myocarditis is the inflammation of the heart muscle and can be caused by a variety of infections, incendiary diseases, and pollutants. It is challenging for an emergency pediatrician to have a sufficiently high degree of suspicion for myocarditis to avoid diagnostic delay given the broad overlap of myocarditis symptoms with other disease processes. The study aimed to evaluate the impact of early presentation and diagnosis on the outcomes of acute myocarditis in children. Patients and Methods We performed a retrospective analysis of the complete records of 80 pediatric patients diagnosed with acute myocarditis between 2015 and 2019 at a single tertiary center in Saudi Arabia. Patients were two weeks to 14 years of age and were admitted to the pediatric intensive care unit (PICU) for various sequelae of myocarditis. Data from routine clinical and laboratory investigations were collected. Results The incidence of delayed presentation at the hospital after the onset of symptoms of myocarditis was 42.5%. A total of 22 (27.5%) patients expired during their hospital stay. There was marginally significant association of earlier presentation with in-hospital survival (80.4% vs 61.8%) and delayed presentation with higher proportion of in-hospital mortality (38.2% vs 19.6%, p=0.064). The rate of mechanical ventilator was also marginally significant in delayed presentation (p=0.068). Shock and multisystem organ failure were the significantly associated manifestations of delayed acute myocarditis presentations. Length of stay in PICU was also significant in delayed presentation group. The impact of presenting symptoms, ECG findings, and use of mechanical ventilator was not significantly associated with delayed presentation. Conclusion An earlier presentation may have a substantial impact on overall prognosis and length of PICU stay and may lead to comparatively lesser frequency of mechanical ventilation use.
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Affiliation(s)
- Waleed H Albuali
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
| | - Mohammad H Al-Qahtani
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
| | - Mohammad A Al Ghamdi
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
| | - Faisal O AlQurashi
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
| | - Amer A Lardhi
- Department of Pediatrics, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia
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Lee JK, Han HS. Coronavirus disease 2019 and mRNA vaccines: what's next - miRNA? Clin Exp Pediatr 2022; 65:302-303. [PMID: 35344980 PMCID: PMC9171463 DOI: 10.3345/cep.2022.00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Joon Kee Lee
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Korea
| | - Heon-Seok Han
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Korea
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Are clinical features and cardiac biomarkers at admission related to severity in pediatric acute myocarditis?: Clinical features and cardiac biomarkers in pediatric acute myocarditis. Arch Pediatr 2022; 29:376-380. [PMID: 35637043 DOI: 10.1016/j.arcped.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 10/04/2021] [Accepted: 03/26/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the factors associated with intensive care requirement and mortality in pediatric myocarditis. METHODS Children aged 28 days to 18 years who were diagnosed with acute myocarditis in a pediatric emergency department between January 2010 and September 2020 were enrolled in the study retrospectively. Demographic and clinical features, cardiac biomarkers, and imaging findings were evaluated. Length of hospital stay, need for hospitalization in the pediatric intensive care unit (PICU), treatments, and survival outcomes were recorded. To define the severity of disease, three groups were created and the data were compared in terms of clinical, laboratory, and imaging findings. The patients treated in the pediatric ward were compared with those hospitalized in the PICU. Ventricular dysfunction was defined in patients with a left ventricular ejection fraction (LVEF) of <50% and these patients were compared with those who had an LVEF of >50%. Also, survivor and non-survivor patients were compared. RESULTS A total number of 62 patients with a median age of 8 years were included. Chest pain and tachycardia were the most common findings on physical examination. The mean LVEF was 59.3 ± 13.0% at admission. Of the patients, 17 were hospitalized in the PICU (27.4%). Chest pain was more common in patients hospitalized in the pediatric ward (p<0.001), and hypotension, vomiting, arrhythmia, were more common and LVEF was lower in patients in the PICU (p = 0.017, p = 0.008, p = 0.006, and p = 0.025, respectively). The children treated in the PICU were younger than those in the pediatric ward (p = 0.009). Troponin I levels were significantly higher in the pediatric ward (p = 0.035), and brain natriuretic peptide (BNP) levels were higher in patients in the PICU (p = 0.012). Death occurred in four patients. Hypotension and vomiting were significantly more common in non-survivors (p = 0.020 and 0.004, respectively). Inotropes and intravenous immunoglobulin (IVIG) were more commonly used in non-survivors (p = 0.001 and p = 0.015, respectively). BNP levels were higher in non-survivors (p = 0.008), and troponin I levels were not different between survivors and non-survivors (p = 0.260). CONCLUSION In pediatric acute myocarditis, lower LVEF, increased BNP, as well as the presence of hypotension and arrhythmia were found to be related to intensive care requirement. Hypotension and vomiting were found to be more common in non-survivors. Due to the possibility of rapidly worsening disease, physicians should be alert to the presence of these findings.
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Aljohani OA, Mackie D, Bratincsak A, Bradley JS, Perry JC. Spectrum of Viral Pathogens Identified in Children with Clinical Myocarditis (Pre-Coronavirus Disease-2019, 2000-2018): Etiologic Agent Versus Innocent Bystander. J Pediatr 2022; 242:18-24. [PMID: 34774573 DOI: 10.1016/j.jpeds.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify the etiologies of viral myocarditis in children in the pre-coronavirus disease 2019 era. STUDY DESIGN This was a retrospective review of all patients (age <18 years) diagnosed with myocarditis and hospitalized at Rady Children's Hospital San Diego between 2000 and 2018. RESULTS Twenty-nine patients met inclusion criteria. Of 28 (97%) patients who underwent testing for viruses, polymerase chain reaction was used in 24 of 28 (86% of cases), and 16 of 24 (67%) detected a virus. Pathogens were rhinovirus (6), influenza A/B (4), respiratory syncytial virus (RSV) (3), coronavirus (3), parvovirus B19 (2), adenovirus (2), and coxsackie B5 virus, enterovirus, and parainfluenza virus type 2 in one case each. Six (21%) patients had no pathogen detected but imaging and other laboratory test results were compatible with myocarditis. Age 0-2 years was associated with RSV, influenza A/B, coronavirus, and enteroviruses (P < .001). Twenty-one patients (72%) experienced full clinical recovery. Three patients (10%) required venoarterial extracorporeal membrane oxygenation (VA-ECMO), and all 3 recovered. Three others (10%) required and underwent successful cardiac transplantation without complications. Two patients (7%) died 9-10 days after hospitalization (1 had RSV and 1 had influenza A/B). Two other patients presented with complete atrioventricular block; 1 case (rhinovirus) resolved spontaneously, and 1 (coronavirus) resolved after support with VA-ECMO. Age <2 years, female sex, lower ejection fraction at admission, and greater initial and peak levels of brain natriuretic peptide were significant predictors of critical outcomes (use of VA-ECMO, listing for cardiac transplantation, and death). CONCLUSIONS Viral nucleic acid-based testing revealed a wider spectrum of viruses that could be associated with myocarditis in children than previously reported and traditionally anticipated. A predilection of certain pathogens in the very young patients was observed. Whether the observed range of viral agents reflects an undercurrent of change in viral etiology or viral detection methods is unclear, but the wider spectrum of viral pathogens found underscores the usefulness of polymerase chain reaction testing to explore possible viral etiologies of myocarditis in children.
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Affiliation(s)
- Othman A Aljohani
- Division of Pediatric Cardiology, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, CA; Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA.
| | - Duncan Mackie
- University of California San Diego School of Medicine, San Diego, CA
| | | | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, CA
| | - James C Perry
- Division of Pediatric Cardiology, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, CA
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Bourgoin P, Aubert L, Joram N, Launay E, Beuchee A, Roue JM, Baruteau A, Fernandez M, Pavy C, Baron O, Flamant C, Liet JM, Ozanne B, Chenouard A. Frequency of Extracorporeal Membrane Oxygenation Support and Outcomes After Implementation of a Structured PICU Network in Neonates and Children: A Prospective Population-Based Study in the West of France. Pediatr Crit Care Med 2021; 22:e558-e570. [PMID: 33950889 DOI: 10.1097/pcc.0000000000002748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the frequency and outcomes on the use of extracorporeal membrane oxygenation (ECMO) among critically ill neonates and children within a structured pediatric critical care network in the West of France. To assess the optimality of decision-making process for patients primarily admitted in non-ECMO centers. DESIGN Observational prospective population-based study from January 2015 to December 2019. PATIENTS Neonates over 34 weeks of gestational age, weighing more than 2,000 g and children under 15 years and 3 months old admitted in one of the 10 units belonging to a Regional Pediatric Critical Care Network. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight-thousand one hundred eighty-nine children and 3,947 newborns were admitted within one of the 10 units of the network over the study period. Sixty-five children (8.1% [95% CI, 6.2-10‰]) and 35 newborns (9.4% [95% CI, 6.4-12%]) required ECMO support. Of these patients, 31 were first admitted to a non-ECMO center, where 20 were cannulated in situ (outside the regional ECMO center) and 11 after transfer to the ECMO regional center. Cardiogenic shock, highest serum lactate level, and cardiac arrest prior to first phone call with the regional ECMO center were associated with higher rate of in situ cannulation. During the study period, most of the patients were cannulated for underlying cardiac issue (42/100), postoperative cardiac surgery instability (38/100), and pediatric (10/100) and neonatal (10/100) respiratory distress syndrome. Patients primarily admitted in non-ECMO centers or not had similar 28-day post-ICU survival rates compared with those admitted in the referral ECMO center (58% vs 51%; p = 0.332). Pre-ECMO cardiac arrest, ECMO, and lower pH at ECMO onset were associated with lower 28-day post-ICU survival. CONCLUSIONS Our local results suggest that a structured referral network for neonatal and pediatric ECMO in the region of Western France facilitated escalation of care with noninferior (or similar) early mortality outcome. Our data support establishing referral networks in other equivalent regions.
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Affiliation(s)
- Pierre Bourgoin
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
- Department of Anesthesiology, University Hospital, Nantes, France
| | - Lucie Aubert
- Department of Pediatrics, University Hospital, Rennes, France
| | - Nicolas Joram
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Elise Launay
- Department of Pediatrics, University Hospital, Nantes, France
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Centre of Research in Epidemiology and StatisticS (CRESS), University of Paris, Paris, France
| | - Alain Beuchee
- Department of Pediatrics, Neonatal Intensive Care Unit, University Hospital, Rennes, France
| | - Jean Michel Roue
- Neonatal and Pediatric Intensive Care Unit, University Hospital, Brest, France
| | - Alban Baruteau
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Modesto Fernandez
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
- Department of Anesthesiology, University Hospital, Nantes, France
| | - Carine Pavy
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Olivier Baron
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Cyril Flamant
- Department of Pediatrics, Neonatal Intensive Care Unit, University Hospital, Nantes, France
| | - Jean Michel Liet
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Bruno Ozanne
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Rennes, France
| | - Alexis Chenouard
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
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Fung RCM, Hon KL, Leung AKC. Acute Myocarditis in Children: An Overview of Treatment and Recent Patents. ACTA ACUST UNITED AC 2021; 14:106-116. [PMID: 32013855 DOI: 10.2174/1872213x14666200204103714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis. METHODS Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine. RESULTS Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking. CONCLUSION This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.
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Affiliation(s)
- Ronald C M Fung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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Vasudeva R, Bhatt P, Lilje C, Desai P, Amponsah J, Umscheid J, Parmar N, Bhatt N, Adupa R, Pagad S, Agrawal P, Donda K, Dapaah-Siakwan F, Yagnik P. Trends in Acute Myocarditis Related Pediatric Hospitalizations in the United States, 2007-2016. Am J Cardiol 2021; 149:95-102. [PMID: 33757784 DOI: 10.1016/j.amjcard.2021.03.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/07/2021] [Accepted: 03/12/2021] [Indexed: 11/24/2022]
Abstract
There has been little exploration of acute myocarditis trends in children despite notable advancements in care over the past decade. We explored trends in pediatric hospitalizations for acute myocarditis from 2007 to 2016 in the United States (US). This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 to 2016, identifying patients ≤18 years hospitalized with acute myocarditis. Patient demographics and incidence trends were examined. Other relevant clinical and resource utilization outcomes were also explored. Out of 60,390,000 weighted pediatric hospitalizations, 6371 were related to myocarditis. The incidence of myocarditis increased from 0.7 to 0.9 per 100,000 children (p <0.0001) over the study period. The mortality decreased from 7.5% to 6.1% (p = 0.02). A significant inflation-adjusted increase by $4,574 in the median hospitalization cost was noted (p = 0.02) while length of stay remained stable (median 6.1 days). Tachyarrhythmias were identified as the most common type of associated arrhythmia. The occurrence of congestive heart failure remained steady at 27%. In conclusion, in-hospital mortality associated with pediatric acute myocarditis has decreased in the United States over years 2007 to 2016 with a concurrent rise in incidence. Despite steady length of stay, hospitalization costs have increased. Future studies investigating long-term outcomes relating to acute myocarditis are warranted.
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Diagnosis and Management of Myocarditis: An Evidence-Based Review for the Emergency Medicine Clinician. J Emerg Med 2021; 61:222-233. [PMID: 34108120 DOI: 10.1016/j.jemermed.2021.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/17/2021] [Indexed: 12/11/2022]
Abstract
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.
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Martins DS, Ait-Ali L, Khraiche D, Festa P, Barison A, Martini N, Benadjaoud Y, Anjos R, Boddaert N, Bonnet D, Aquaro GD, Raimondi F. Evolution of acute myocarditis in a pediatric population: An MRI based study. Int J Cardiol 2020; 329:226-233. [PMID: 33359333 DOI: 10.1016/j.ijcard.2020.12.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac Magnetic Resonance (CMR) data regarding myocarditis presentation and disease course is still lacking in pediatric patients. We evaluate baseline CMR and evolution of functional and tissue abnormalities in children with acute myocarditis. METHODS CMR was performed in 125 patients with clinical diagnosis of acute myocarditis. Clinical follow-up was performed for a median of 498 (214-923) days. RESULTS LVEF was depressed (<55%) in 56 cases (45%) upon baseline CMR. LGE was found in 93 patients (77%) of cases. LGE was exclusively subepicardial in 29 patients (23%), while other LGE patterns (midwall/mixed) were present in 64 (51%). CMR was repeated in 92 (74%) patients. 67% presented recover of function at a median of 170 (70-746) days after onset of symptoms. Midwall/mixed LGE pattern had a statistically significant correlation with absent recover of function (OR 0.20 p 0.036). Thirteen patients (16%) had recovery from LV dysfunction but with persistence of LGE. Sub-epicardial pattern of LGE (OR 3.33, 95% CI 1.08-10.2, p = 0.036) and the presence of fever at admission (OR 4.67, 95% CI 1.16-18.7, p = 0.03) were associated with a significantly higher likelihood of complete normalization while midwall/mixed LGE pattern was associated with non-recovery. CONCLUSIONS In pediatric myocarditis, midwall/mixed LGE pattern is associated with absent recover of function. Patients with recover of function may still have persistence of LGE, while a complete recovery from functional and tissue abnormalities is found only in a third of patients. Midwall/mixed pattern of LGE at first MRI was associated to worse outcome.
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Affiliation(s)
- Duarte S Martins
- Unité médico-chirurgicale de cardiologie congénitale et pédiatrique, centre de référence des maladies cardiaques congénitales complexes - M3C, Hôpital universitaire Necker-Enfants Malades, Université de Paris, France and Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
| | - Lamia Ait-Ali
- Institute of Clinical Physiology CNR, UO Massa and Fondazione G. Monasterio, CNR-Regione Toscana, Italy
| | - Diala Khraiche
- Unité médico-chirurgicale de cardiologie congénitale et pédiatrique, centre de référence des maladies cardiaques congénitales complexes - M3C, Hôpital universitaire Necker-Enfants Malades, Université de Paris, France
| | | | | | | | - Yasmine Benadjaoud
- Laboratory of Embriology and Genetic Malformation, INSERM UMR 1163, Imagine Institute, Université de Paris, F-75015 Paris, France
| | - Rui Anjos
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Nathalie Boddaert
- Pediatric Radiology Unit, Hôpital universitaire Necker-Enfants Malades, Université de Paris, France
| | - Damien Bonnet
- Unité médico-chirurgicale de cardiologie congénitale et pédiatrique, centre de référence des maladies cardiaques congénitales complexes - M3C, Hôpital universitaire Necker-Enfants Malades, Université de Paris, France
| | | | - Francesca Raimondi
- Unité médico-chirurgicale de cardiologie congénitale et pédiatrique, centre de référence des maladies cardiaques congénitales complexes - M3C, Hôpital universitaire Necker-Enfants Malades, Université de Paris, France and Laboratory of Embriology and Genetic Malformation, INSERM UMR 1163, Imagine Institute, F-75015 Paris, France
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Abstract
Myocarditis in the pediatric population can be a challenging diagnosis to make and often requires utilization of multiple diagnostic modalities. The cause is often due to a viral infection with activation of the innate and acquired immune response with either recovery or disease progression. Laboratory testing often includes inflammatory markers, cardiac troponin levels, and natriuretic peptides. Noninvasive testing should include electrocardiogram, echocardiogram, and possibly an MRI. Treatment of myocarditis remains controversial with most providers using immune modulators with intravenous immunoglobulin and corticosteroids.
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Lee EP, Chu SC, Huang WY, Hsia SH, Chan OW, Lin CY, Su YT, Chang YS, Chung HT, Wu HP, Lin JJ. Factors Associated With In-hospital Mortality of Children With Acute Fulminant Myocarditis on Extracorporeal Membrane Oxygenation. Front Pediatr 2020; 8:488. [PMID: 32984204 PMCID: PMC7481354 DOI: 10.3389/fped.2020.00488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
Aim: To analyze the factors associated with in-hospital mortality of children with acute fulminant myocarditis on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods: This was a retrospective cohort study using chart reviews of patients diagnosed with acute fulminant myocarditis at the pediatric intensive care unit of two tertiary medical centers between January 1, 2005 and December 31, 2017. The inclusion criteria for this study were: (1) age from 1 month to 18 years; (2) diagnosed with acute myocarditis; (3) cardiogenic shock and need vasoactive-inotropic score ≥20 within 48 h after the use of vasoactive-inotropic agents; and (4) the need for ECMO placement. Results: Thirty-three children with acute fulminant myocarditis who needed ECMO were included. Clinical parameters were retrospectively reviewed. The overall survival rate was 69.6%. Higher levels of pre-ECMO troponin-I and pre-ECMO lactate, and lower post-ECMO left ventricular ejection fraction (LVEF) were significantly associated with in-hospital mortality in univariate analysis. Only higher pre-ECMO lactate and lower post-ECMO LVEF remained as predictors for in-hospital mortality in multivariate analysis. The areas under the curve of pre-ECMO lactate and post-ECMO LVEF in predicting survival were 0.848 (95% CI, 0.697-0.999, p = 0.002) and 0.824 (95% CI, 0.704-0.996, p = 0.01), respectively. A pre-ECMO lactate level of 79.8 mg/dL and post-ECMO LVEF of 39% were appropriate cutoff points to predict mortality. Conclusion: Pre-ECMO lactate level was associated with mortality in children with acute fulminant myocarditis, with an optimal cutoff value of 79.8 mg/dL. After VA-ECMO implantation, post-ECMO LVEF was associated with mortality, with an optimal cutoff value of 39%. The use of LVADs or urgent heart transplantation should be considered if the post-ECMO LVEF does not improve.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Sheng-Chih Chu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Cardiovascular Internal Medicine, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Pediatrics, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan.,National Defense Medical Center, Taoyuan, Taiwan
| | - Wun-Yan Huang
- Department of Pediatric Emergency Medicine, China Medical University Children Hospital, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ying Lin
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Ting Su
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Sheng Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Cardiovascular Surgery, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hung-Tao Chung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Cardiovascular Internal Medicine, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, China Medical University Children Hospital, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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