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Vidusa L, Kalejs O, Maca-Kaleja A, Strumfa I. Role of Endomyocardial Biopsy in Diagnostics of Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12092104. [PMID: 36140505 PMCID: PMC9497694 DOI: 10.3390/diagnostics12092104] [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: 07/03/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022] Open
Abstract
Endomyocardial biopsy as the cornerstone of diagnostics has been re-evaluated throughout the years, leaving unanswered questions on the precedence of it. The reported incidence of myocarditis has increased during the pandemic of coronavirus disease 2019 (COVID-19), reinforcing discussions on appropriate diagnostics of myocarditis. By analysis of evidence-based literature published within the last demi-decade, we aimed to summarize the most recent information in order to evaluate the current role of endomyocardial biopsy in diagnostics and management of myocarditis. For the most part, research published over the last five years showed ongoing uncertainty regarding the use, informativeness, safety and necessity of performing a biopsy. Special circumstances, such as fulminant clinical course or failure to respond to empirical treatment, were reconfirmed as justified indications, with a growing applicability of non-invasive diagnostic approaches for most other cases. We concluded that endomyocardial biopsy, if performed properly and with adjunct diagnostic methods, holds a critical role for treatment correction in specific histological subtypes of myocarditis and for differential diagnosis between immune-mediated myocarditis and secondary infections due to immunosuppressive treatment. A high level of possible misdiagnosing was detected, indicating the need to review terminology used to describe findings of myocardial inflammation that did not meet Dallas criteria.
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Affiliation(s)
- Liga Vidusa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Aija Maca-Kaleja
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Ilze Strumfa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Correspondence:
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Baritussio A, Schiavo A, Basso C, Giordani AS, Cheng CY, Pontara E, Cattini MG, Bison E, Gallo N, De Gaspari M, Carturan E, Thiene G, Tarantini G, Plebani M, Rizzo S, Gregori D, Iliceto S, Marcolongo R, Caforio ALP. Predictors of relapse, death or heart transplantation in myocarditis before the introduction of immunosuppression: negative prognostic impact of female gender, fulminant onset, lower ejection fraction and serum autoantibodies. Eur J Heart Fail 2022; 24:1033-1044. [PMID: 35377503 DOI: 10.1002/ejhf.2496] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Outcome predictors in myocarditis are not well defined; we aimed at identifying predictors of death, heart transplantation (HTx) and relapse before the introduction of immunosuppression. METHODS AND RESULTS From 1992 to 2012 we consecutively included 466 patients (68% male, 37±17 years, single centre recruitment, median follow-up 50 months), 216 with clinically suspected and 250 with biopsy (Bx)-proven myocarditis. Serum anti heart (AHA) and antiintercalated disk (AIDA) auto-antibodies were measured by indirect immunofluorescence. We performed univariable and multivariable analysis of clinical and diagnostic features at diagnosis. Survival free from death or HTx at 10 years was 83% in the whole group and was lower in Bx- proven vs. clinically suspected myocarditis (76% vs 94% respectively, p<0.001). Female gender (hazard ratio (HR) 2.7, 95% Confidence Intervals (CI) 1.1-6.5), fulminant presentation (HR 13.77, CI 9.7-261.73), high-titre organ-specific AHA (HR 4.2, CI 1.2-14.7) and anti-nuclear antibodies (ANA) (HR 5.2, CI 2.1-12.8) were independent predictors of death or HTx; higher echocardiographic left ventricular ejection fraction (LVEF) at diagnosis was protective, with a 0.93 times risk reduction for each 1% LVEF increase (CI 0.89-0.96). History of myocarditis at diagnosis (HR 8.5, CI 3.5-20.7) was independent predictor of myocarditis relapse at follow-up; older age was protective (HR 0.95, CI 0.91-0.99). Predictors of death, HTx and relapse did not differ in Bx-proven vs. clinically suspected myocarditis. CONCLUSIONS Young age and a previous myocarditis were independent relapse predictors; female gender, fulminant onset, lower LVEF at presentation and high-titre organ-specific AHA and ANA were independent predictors of death and HTx, suggesting that autoimmune features predict worse prognosis.
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Affiliation(s)
- Anna Baritussio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alessandro Schiavo
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Cristina Basso
- Cardiac Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Silvio Giordani
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Chun-Yan Cheng
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elena Pontara
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Maria Grazia Cattini
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elisa Bison
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicoletta Gallo
- Department of Laboratory Medicine, University of Padua, Padua, Italy
| | - Monica De Gaspari
- Cardiac Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elisa Carturan
- Cardiac Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gaetano Thiene
- Cardiac Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University of Padua, Padua, Italy
| | - Stefania Rizzo
- Cardiac Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Statistics, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Renzo Marcolongo
- Haematology and Clinical Immunology, Department of Medicine, University of Padua, Padua, Italy
| | - Alida Linda Patrizia Caforio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Abstract
Introduction Inflammatory conditions affecting the heart and surrounding tissues have been recently reported following mRNA vaccination. Evaluating trends in the epidemiology of these events and possible mechanisms related to vaccination will enhance vaccine safety surveillance and inform best practices for future vaccine campaigns. Areas covered Epidemiology of the burden of vaccine-associated myocarditis are reviewed. Key summaries of available data from public health advisory bodies and vaccine safety surveillance databases are critically reviewed. The possible biological pathways for vaccine-associated heart inflammations are introduced. A critical synthesis of available information to inform vaccine recommendations and best practices is provided. The citations were selected by the authors based on PubMed searches of the literature, national vaccine safety surveillance databases and summaries from national public health bodies. Expert opinion Myocarditis may be associated with vaccination, through several biological mechanisms. Studies have shown that live viral vaccinations can act as a trigger for hypersensitivity inflammatory reactions, but further work is required to examine how the mRNA formulation may induce these autoimmune responses. Given that the risk of these adverse events is low, and the benefit of protection against disease is so great, the receipt of mRNA vaccines is recommended.
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Affiliation(s)
- Charlotte Switzer
- Department of Health Research Evidence and Impact, McMaster University, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Evidence and Impact, McMaster University, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Piccirillo F, Watanabe M, Di Sciascio G. Diagnosis, treatment and predictors of prognosis of myocarditis. A narrative review. Cardiovasc Pathol 2021; 54:107362. [PMID: 34192559 DOI: 10.1016/j.carpath.2021.107362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/31/2022] Open
Abstract
Although it has been recognized for almost two centuries, myocarditis is still a challenging diagnosis due to the wide heterogeneity of its clinical manifestations and evolution. Moreover, the diagnostic gold standard, endomyocardial biopsy (EMB), is infrequently used, making hard to determine the exact incidence of myocarditis. Clinical presentation includes a wide range of symptoms, ranging from asymptomatic or subclinical disease with mild dyspnea and chest pain to sudden death, due to cardiogenic shock or malignant ventricular arrhythmias. Equally, the evolution of myocarditis largely varies: albeit short-term prognosis is usually good, with complete or partial recovery, dilated cardiomyopathy with chronic heart failure is the major long-term consequence of myocarditis, developing often several years after the acute onset. This narrative review aims to summarize the current knowledge about myocarditis, with a particular attention to predictors of short- and long-term prognosis, in order to provide a rational and practical approach to the diagnosis, evaluation and treatment of suspected myocarditis.
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Affiliation(s)
- Francesco Piccirillo
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy.
| | - Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Germano Di Sciascio
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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Abstract
PURPOSE OF REVIEW The clinical syndrome of coronavirus disease 2019 (COVID-19) has become a global pandemic leading to significant morbidity and mortality. Cardiac dysfunction is commonly seen in these patients, often presenting as clinical heart failure. Accordingly, we aim to provide a comprehensive review on COVID-19 myocarditis and its long-term heart failure sequelae. RECENT FINDINGS Several suspected cases of COVID-19 myocarditis have been reported. It is often not clear if the acute myocardial dysfunction is caused by myocarditis or secondary to generalized inflammatory state of cytokine release or microvascular thrombotic angiopathy. Ischemia may also need to be ruled out. Regardless, myocardial dysfunction in these patients is associated with poor overall prognosis. Laboratory testing, echocardiography, cardiac magnetic resonance imaging, and even endomyocardial biopsy may be needed for timely diagnosis. Several treatment strategies have been described, including both supportive and targeted therapies. SUMMARY COVID-19 can cause a spectrum of ventricular dysfunction ranging from mild disease to fulminant myocarditis with hemodynamic instability. Future research is needed to understand the true prevalence of COVID-19 myocarditis, as well as to better define various diagnostic protocols and treatment strategies.
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Affiliation(s)
- Jing Liu
- Section of Cardiology, Department of Medicine, Baylor College of Medicine
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center
| | - Umair Khalid
- Section of Cardiology, Medical Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Hua TR, Zhang SY. Cardiomyopathies in China: A 2018-2019 state-of-the-art review. Chronic Dis Transl Med 2020; 6:224-238. [PMID: 33336168 PMCID: PMC7729112 DOI: 10.1016/j.cdtm.2020.05.006] [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: 03/29/2020] [Indexed: 11/02/2022] Open
Abstract
Cardiomyopathies are diseases of the cardiac muscle and are often characterized by ventricular dilation, hypertrophy, and cardiac arrhythmia. Patients with cardiomyopathies often experience sudden death and cardiac failure and require cardiac transplantation during the course of disease progression. Early diagnosis, differential diagnosis, and genetic consultation depend on imaging techniques, genetic testing, and new emerging diagnostic tools such as serum biomarkers. The molecular genetics of cardiomyopathies has been widely studied recently. The discovery of mechanisms underlying heterogeneity and overlapping of the phenotypes of cardiomyopathies has revealed the existence of disease modifiers, and this has led to the emergence of novel disease-modifying therapy. This 2018-2019 state-of-the-art review outlines the pathogenesis, diagnosis, and treatment of cardiomyopathies in China.
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Affiliation(s)
- Tian-Rui Hua
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shu-Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Kariyanna PT, Sutarjono B, Grewal E, Singh KP, Aurora L, Smith L, Chandrakumar HP, Jayarangaiah A, Goldman SA, Salifu MO, McFarlane IM. A Systematic Review of COVID-19 and Myocarditis. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:299-305. [PMID: 32747875 PMCID: PMC7397751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The COVID-19 infection which emerged in December 2019, is caused by the virus SARS-CoV-2. Infection with this virus can lead to severe respiratory illness, however, myocarditis has also been reported. The purpose of this study is to identify the clinical features of myocarditis in COVID-19 patients. METHODS A systematic review was conducted to investigate characteristics of myocarditis in patients infected with COVID-19 using the search term "Coronavirus" or "COVID" and "myocarditis," "heart," or "retrospective." Case reports and retrospective studies were gathered by searching Medline/Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases. 11 articles were selected for review. RESULTS COVID-19 myocarditis affected patients over the age of 50 and incidences among both genders were equally reported. Patients presented with dyspnea, cough, fever with hypotension and chest pain. Laboratory tests revealed leukocytosis with increased C-reactive protein, while arterial blood gas analysis demonstrated respiratory acidosis. All cardiac markers were elevated. Radiographic imaging of the chest showed bilateral ground glass opacities or bilateral infiltrates, while cardiac magnetic resonance imaging produced late gadolinium enhancements. Electrocardiography demonstrated ST-segment elevation or inverted T waves, while echocardiography revealed reduced left ventricular ejection fraction with cardiomegaly or increased wall thickness. Management with corticosteroids was favored in most cases, followed by antiviral medication. The majority of studies reported either recovery or no further clinical deterioration. CONCLUSION Current available data on COVID-19 myocarditis is limited. Further research is needed to advance our understanding of COVID-19 myocarditis.
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Affiliation(s)
- Pramod Theetha Kariyanna
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Bayu Sutarjono
- Saba University School of Medicine, 27 Jackson Road, Devens, MA 01434, USA
| | - Ekjot Grewal
- Department of Emergency Medicine, Brookdale University Hospital and Medical Center, 1 Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Kamal Preet Singh
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Lyudmila Aurora
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Leanna Smith
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Harshith Priyan Chandrakumar
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Apoorva Jayarangaiah
- Division of Hematology and Oncology, Department of Internal Medicine, Albert Einstein College of medicine/NYC + HHC Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY, U.S.A- 1046
| | - Sarah A. Goldman
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Moro O. Salifu
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Isabel M. McFarlane
- Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA,Corresponding author:
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