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Domínguez F, Uribarri A, Larrañaga-Moreira JM, Ruiz-Guerrero L, Pastor-Pueyo P, Gayán-Ordás J, Fernández-González B, Esteban-Fernández A, Barreiro M, López-Fernández S, Gutiérrez-Larraya Aguado F, Pascual-Figal D. Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:667-679. [PMID: 38763214 DOI: 10.1016/j.rec.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 05/21/2024]
Abstract
Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.
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Affiliation(s)
- Fernando Domínguez
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Aitor Uribarri
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Luis Ruiz-Guerrero
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Pablo Pastor-Pueyo
- Servicio de Cardiología, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Jara Gayán-Ordás
- Servicio de Cardiología, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | | | | | - Manuel Barreiro
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | | | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, El Palmar, Murcia, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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2
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Vicenzetto C, Giordani AS, Menghi C, Baritussio A, Peloso Cattini MG, Pontara E, Bison E, Rizzo S, De Gaspari M, Basso C, Thiene G, Iliceto S, Marcolongo R, Caforio ALP. The Role of the Immune System in Pathobiology and Therapy of Myocarditis: A Review. Biomedicines 2024; 12:1156. [PMID: 38927363 PMCID: PMC11200507 DOI: 10.3390/biomedicines12061156] [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: 03/29/2024] [Revised: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024] Open
Abstract
The role of the immune system in myocarditis onset and progression involves a range of complex cellular and molecular pathways. Both innate and adaptive immunity contribute to myocarditis pathogenesis, regardless of its infectious or non-infectious nature and across different histological and clinical subtypes. The heterogeneity of myocarditis etiologies and molecular effectors is one of the determinants of its clinical variability, manifesting as a spectrum of disease phenotype and progression. This spectrum ranges from a fulminant presentation with spontaneous recovery to a slowly progressing, refractory heart failure with ventricular dysfunction, to arrhythmic storm and sudden cardiac death. In this review, we first examine the updated definition and classification of myocarditis at clinical, biomolecular and histopathological levels. We then discuss recent insights on the role of specific immune cell populations in myocarditis pathogenesis, with particular emphasis on established or potential therapeutic applications. Besides the well-known immunosuppressive agents, whose efficacy has been already demonstrated in human clinical trials, we discuss the immunomodulatory effects of other drugs commonly used in clinical practice for myocarditis management. The immunological complexity of myocarditis, while presenting a challenge to simplistic understanding, also represents an opportunity for the development of different therapeutic approaches with promising results.
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Affiliation(s)
- Cristina Vicenzetto
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Andrea Silvio Giordani
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Caterina Menghi
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Anna Baritussio
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Maria Grazia Peloso Cattini
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Elena Pontara
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Elisa Bison
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Stefania Rizzo
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy (G.T.)
| | - Monica De Gaspari
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy (G.T.)
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy (G.T.)
| | - Gaetano Thiene
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy (G.T.)
| | - Sabino Iliceto
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Renzo Marcolongo
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
| | - Alida Linda Patrizia Caforio
- Cardiology and Cardioimmunology Laboratory, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (C.V.); (R.M.)
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3
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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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4
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Naseeb MW, Adedara VO, Haseeb MT, Fatima H, Gangasani S, Kailey KR, Ahmed M, Abbas K, Razzaq W, Qayyom MM, Abdin ZU. Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review. Cureus 2023; 15:e40439. [PMID: 37456487 PMCID: PMC10349211 DOI: 10.7759/cureus.40439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Giant cell myocarditis (GCM) is a rare, often rapidly progressive, and potentially fatal disease because of myocardium inflammation due to the infiltration of giant cells triggered by infectious as well as non-infectious etiologies. Several studies have reported that GCM can occur in patients of all ages but is more commonly found in adults. It is relatively more common among African American and Hispanic patients than in the White population. Early diagnosis and treatment are critical. Electrocardiogram (EKG), complete blood count, erythrocyte sedimentation rate, C-reactive protein, and cardiac biomarkers such as troponin and brain natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (MRI), myocardial biopsy, and myocardial gene profiling are useful diagnostic tools. Current research has identified several potential biomarkers for GCM, including myocarditis-associated immune cells, cytokines, and other chemicals. The standard of care for GCM includes aggressive immunosuppressive therapy with corticosteroids and immunomodulatory agents like rituximab, cyclosporine, and infliximab, which have shown promising results in GCM by balancing the immune system and preventing the attack on healthy tissues, resulting in the reduction of inflammation, promotion of healing, and decreasing the necessity for cardiac transplantation. Without immunosuppression, the chance of mortality or cardiac surgery was 100%. Multiple studies have revealed that a treatment combination of corticosteroids and immunomodulatory agents is superior to corticosteroids alone. Combination therapy significantly increased transplant-free survival (TFS) and decreased the likelihood of heart transplantation, hence improving overall survival. It is important to balance the benefits of immunosuppression with its potentially adverse effects. In conclusion, immunomodulatory therapy adds significant long-term survival benefits to GCM.
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Affiliation(s)
| | - Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | | | - Hareem Fatima
- Internal Medicine, Federal Medical College, Islamabad, PAK
| | - Swapna Gangasani
- Internal Medicine, New York Medical College (NYMC) St. Mary's General Hospital and Saint Clare's Hospitals, New Jersey, USA
| | - Kamaljit R Kailey
- Medicine and Surgery, Gian Sagar Medical College and Hospital, Patiala, IND
| | - Moiz Ahmed
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
| | | | | | - Zain U Abdin
- Medicine, District Headquarter Hospital, Faisalabad, PAK
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5
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Giordani AS, Baritussio A, Vicenzetto C, Peloso-Cattini MG, Pontara E, Bison E, Fraccaro C, Basso C, Iliceto S, Marcolongo R, Caforio ALP. Fulminant Myocarditis: When One Size Does Not Fit All - A Critical Review of the Literature. Eur Cardiol 2023; 18:e15. [PMID: 37405349 PMCID: PMC10316338 DOI: 10.15420/ecr.2022.54] [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: 10/19/2022] [Accepted: 12/12/2022] [Indexed: 07/06/2023] Open
Abstract
Fulminant myocarditis, rather than being a distinct form of myocarditis, is instead a peculiar clinical presentation of the disease. The definition of fulminant myocarditis has varied greatly in the last 20 years, leading to conflicting reports on prognosis and treatment strategies, mainly because of varied inclusion criteria in different studies. The main conclusion of this review is that fulminant myocarditis may be due to different histotypes and aetiologies that can be diagnosed only by endomyocardial biopsy and managed by aetiology-directed treatment. This life-threatening presentation requires rapid, targeted management both in the short term (mechanical circulatory support, inotropic and antiarrhythmic treatment and endomyocardial biopsy) and in the long term (including prolonged follow-up). Fulminant presentation has also recently been identified as a risk factor for worsened prognosis, even long after the resolution of the acute phase of myocarditis.
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Affiliation(s)
- Andrea Silvio Giordani
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Anna Baritussio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Cristina Vicenzetto
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Maria Grazia Peloso-Cattini
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Elena Pontara
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Elisa Bison
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Chiara Fraccaro
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Sabino Iliceto
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Renzo Marcolongo
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Alida Linda Patrizia Caforio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
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6
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Frankel ES, Hajduczok AG, Rajapreyar IN, Brailovsky Y. Recurrent giant cell myocarditis after heart transplant: a case report. Eur Heart J Case Rep 2022; 6:ytac362. [PMID: 36157972 PMCID: PMC9491859 DOI: 10.1093/ehjcr/ytac362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/11/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Giant cell myocarditis (GCM) is a rare but well-known cause of fulminant myocarditis. Despite optimal medical therapy, many patients progress to orthotopic heart transplant (OHT). We present a case of recurrent GCM following OHT, including complex considerations in patient management and infectious sequelae.
Case summary
A 33-year-old previously healthy male presented with 2 months of worsening shortness of breath. Transthoracic echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 30–35%. After ruling out an ischaemic aetiology, he was discharged on guideline-directed medical therapy and later presented with productive cough, worsening dyspnoea on exertion, and diarrhoea. He was found to have elevated troponins and N-terminal pro-brain natriuretic peptide, lactic acidosis, progression of severe bi-ventricular dysfunction on TTE and right heart catheterization, and low cardiac index (1.0 L/min/m2) requiring inotropes. He then required left ventricular assist device as a bridge to OHT. Pathology of the apical core diagnosed GCM as the cause of his fulminant heart failure. He eventually underwent heart transplantation, which was complicated by recurrent GCM. Treatment required intensification of his immunosuppressive regimen, which led to multiple infectious sequelae including norovirus, Shiga-like toxin producing Escherichia coli, and disseminated nocardia of the lung and brain. As of the most recent follow-up, the patient is currently clinically stable.
Discussion
Although recurrent GCM after OHT has been reported in the literature, the prognosis is not well understood and there are no clear guidelines regarding management. This case summarizes clinical considerations, treatment strategies, and adverse effects of recurrent GCM treatment.
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Affiliation(s)
- Eitan S Frankel
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University Hospital , 925 Chestnut Street, Suite 200, Philadelphia, PA 19107 , USA
| | - Alexander G Hajduczok
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University Hospital , 925 Chestnut Street, Suite 200, Philadelphia, PA 19107 , USA
| | - Indranee N Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University Hospital , 925 Chestnut Street, Suite 200, Philadelphia, PA 19107 , USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University Hospital , 925 Chestnut Street, Suite 200, Philadelphia, PA 19107 , USA
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7
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Taimeh Z, Tang WHW. New Advances and Ongoing Challenges in the Use of Biologic Agents in Cardiac Sarcoidosis and Other Inflammatory Cardiomyopathies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00918-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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8
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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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9
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Affiliation(s)
- Nowell M. Fine
- Division of Cardiology, Department of Cardiac Sciences and Community Health Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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10
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Abstract
Myocarditis is generally a mild and self-limited consequence of systemic infection of cardiotropic viruses. However, patients can develop a temporary or permanent impairment of cardiac function including acute cardiomyopathy with hemodynamic compromise or severe arrhythmias. In this setting, specific causes of inflammation are associated with variable risks of death and transplantation. Recent translational studies suggest that treatments tailored to specific causes of myocarditis may impact clinical outcomes when added to guideline-directed medical care. This review summarizes recent advances in translational research that influence the utility of endomyocardial biopsy for the management of inflammatory cardiomyopathies. Emerging therapies for myocarditis based on these mechanistic hypotheses are entering clinical trials and may add to the benefits of established heart failure treatment.
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Affiliation(s)
- Carsten Tschöpe
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Guillermo Torre-Amione
- Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX (G.T.-A.).,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Nuevo León, Mexico (G.T.-A.)
| | - Sophie Van Linthout
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
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11
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Sirolimus for Recurrent Giant Cell Myocarditis After Heart Transplantation: A Unique Therapeutic Strategy. Am J Ther 2019; 26:600-603. [DOI: 10.1097/mjt.0000000000000796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Sánchez-Trujillo L, Jerjes-Sanchez C, Rodriguez D, Panneflek J, Ortiz-Ledesma C, Garcia-Rivas G, Torre-Amione G. Phase II clinical trial testing the safety of a humanised monoclonal antibody anti-CD20 in patients with heart failure with reduced ejection fraction, ICFEr-RITU2: study protocol. BMJ Open 2019; 9:e022826. [PMID: 30918029 PMCID: PMC6475246 DOI: 10.1136/bmjopen-2018-022826] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Chronic heart failure with reduced ejection fraction (HFrEF) treatment targets neurohormonal inhibition; however, our experimental observations and the recent clinical evidence in myocardial infarction and heart transplant patients support the anti-inflammatory pathway as a potential novel therapeutic target. Therefore, we aimed to assess the safety of human monoclonal antibody-CD20 (rituximab) in patients with HFrEF. METHODS AND ANALYSIS We designed this protocol according to the Standard Protocol Items: Recommendations for Interventional Trials guidelines as a phase II, single-centred, single group and prospective clinical trial. We hypothesise that the use of a monoclonal antibody, rituximab, could be a potentially safe new agent in HFrEF management. We will include patients with EF≤40%, New York Heart Association functional class III/IV and unresponsive to standard treatment. We will use a dosing regimen (1000 mg) previously applied to post-transplant patients and patients with rheumatoid arthritis with favourable results, aiming to provide supplementary evidence of safety in patients with HFrEF. We designed strategies tailored to preserving the integrity of patient safety. The date of study initiation will be 29th of May 2019. ETHICS AND DISSEMINATION The following protocol was approved by IRB committees, and as a requirement, all patients need to sign an informed consent form before being subjected to any procedure prior to the initiation of the study. We are aware that the trial will be run in patients who due to their cardiovascular functional class, have reserved prognosis, with no known therapy that leads to improvement. Hence, this trial searches to establish the safety of an alternative strategy in ameliorating prognosis. Regardless of the study outcomes, whether favourable or not, they will be published. If a favourable outcome is evidenced, it will prompt performing a phase III, efficacy-based study. TRIAL REGISTRATION NUMBER The trial was approved by the IRB (CONBIOÉTICA-19-CEI-011-20161017 and COFEPRIS-17-CI-19-039-003), and registered at Clinicaltrials.gov (NCT03332888; Pre-Results).
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Affiliation(s)
- Luis Sánchez-Trujillo
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - Carlos Jerjes-Sanchez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - David Rodriguez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - Jathniel Panneflek
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - Claudia Ortiz-Ledesma
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - Gerardo Garcia-Rivas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
| | - Guillermo Torre-Amione
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, N.L., Mexico
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13
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Látal J, Špaček M, Přeček J, Tüdös Z, Hutyra M, Tichý T, Táborský M. Giant-cell myocarditis - A case report and a brief review. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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Ammirati E, Oliva F, Belli O, Bonacina E, Pedrotti P, Turazza FM, Roghi A, Paino R, Martinelli L, Frigerio M. Giant cell myocarditis successfully treated with antithymocyte globuline and extracorporeal membrane oxygenation for 21 days. J Cardiovasc Med (Hagerstown) 2018; 17 Suppl 2:e151-e153. [PMID: 25643196 DOI: 10.2459/jcm.0000000000000250] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: A 31-year-old man presenting with cardiogenic shock and left ventricular ejection fraction of 10% received the diagnosis of giant cell myocarditis by endomyocardial biopsy. The patient was successfully treated with high-dose inotropes, intra-aortic balloon pump and venoarterial extracorporeal membrane oxygenation for 21 days associated with combined immunosuppression (thymoglobulin, steroids, cyclosporine). Immunosuppression including thymoglobulin is the regimen associated with the highest probability of recovery in case of giant cell myocarditis. Immunosuppression needs time to be effective; thus, hemodynamic support must be guaranteed. In the present case, we observed that full recovery can be obtained up to 21 days of support with extracorporeal membrane oxygenation and adequate immunosuppression.
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Affiliation(s)
- Enrico Ammirati
- 'Angelo De Gasperis' Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy
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15
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Abstract
PURPOSE OF REVIEW In this paper we will review the modern diagnostic approach to patients with clinically suspected myocarditis as well as the treatment modalities and strategy in light of up-to-date clinical experience and scientific evidence. RECENT FINDINGS Rapidly expanding evidence suggests that myocardial inflammation is frequently underdiagnosed or overlooked in clinical practice, although new therapeutic options have been validated. Moreover, the available evidence suggests that subclinical cardiac involvement has negative prognostic impact on morbidity and mortality and should be actively investigated and adequately treated. Myocarditis represents a growing challenge for physicians, due to increased referral of patients for endomyocardial biopsy (EMB) or cardiac magnetic resonance (CMR), and requires a highly integrated management by a team of caring physicians.
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16
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Kasouridis I, Majo J, MacGowan G, Clark AL. Giant cell myocarditis presenting with acute heart failure. BMJ Case Rep 2017; 2017:bcr-2017-219574. [PMID: 28536222 DOI: 10.1136/bcr-2017-219574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Idiopathic giant cell myocarditis (GCM) is a rare and rapidly progressing form of myocarditis predominantly affecting younger people. We report a case of a 23-year-old athletic patient who presented with features of acute heart failure due to GCM and discuss his management that included a left ventricular assist device as a bridge to transplant. He died immediately following the transplant.We also review the literature on this rare disease, highlighting the advances in the management of the disease including immunosuppressive therapy, ventricular assist devices and heart transplantation.
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Affiliation(s)
| | - Joaquim Majo
- Histopathology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Guy MacGowan
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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17
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Alemtuzumab as a novel treatment for refractory giant cell myocarditis after heart transplantation. J Heart Lung Transplant 2016; 35:256-8. [DOI: 10.1016/j.healun.2015.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 09/02/2015] [Accepted: 10/01/2015] [Indexed: 11/23/2022] Open
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18
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Donor-derived exosomes induce specific regulatory T cells to suppress immune inflammation in the allograft heart. Sci Rep 2016; 7:20077. [PMID: 26822278 PMCID: PMC4731812 DOI: 10.1038/srep20077] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 12/09/2015] [Indexed: 02/08/2023] Open
Abstract
To inhibit the immune inflammation in the allografts can be beneficial to organ transplantation. This study aims to induce the donor antigen specific regulatory T cells (Treg cell) inhibit the immune inflammation in the allograft heart. In this study, peripheral exosomes were purified from the mouse serum. A heart transplantation mouse model was developed. The immune inflammation of the allograft heart was assessed by histology and flow cytometry. The results showed that the donor antigen-specific T helper (Th)2 pattern inflammation was observed in the allograft hearts; the inflammation was inhibited by immunizing the recipient mice with the donor-derived exosomes. Purified peripheral exosomes contained integrin MMP1a; the latter induced CD4+ T cells to express Fork head protein-3 and transforming growth factor (TGF)-β via inhibiting the Th2 transcription factor, GATA binding protein 3, in CD4+ T cells. Administration with the donor-derived exosomes significantly prolonged the allograft heart survival. We conclude that the donor-derived peripheral exosomes have the capacity to inhibit the immune inflammation in the allograft heart via inducing specific Treg cells, implicating that administration with the donor-derived exosomes may be beneficial to cardiac transplantation.
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Abstract
Idiopathic giant cell myocarditis (IGCM) is a rare disease causing progressive myocarditis characterized by myocardial necrosis and giant cells. Patients often present with rapidly progressive heart failure, ventricular arrhythmias, and heart block. Without treatment, the disease often results in progressive pump failure requiring urgent cardiac transplantation or the need for mechanical circulatory support. The underlying pathophysiologic mechanisms are not yet defined but appear to involve genetics, autoimmune disorders, and possibly environmental factors such as viruses. Combined immunosuppressive regimens appear to prolong survival from death or cardiac transplant. Nevertheless, cardiac transplant is an effective treatment. The disease can recur in the transplanted heart resulting in death or the need for retransplant.
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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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