Clinical Features of Acute and Fulminant Myocarditis in Children - 2nd Nationwide Survey by Japanese Society of Pediatric Cardiology and Cardiac Surgery

Survival trends of extracorporeal membrane oxygenation support for pediatric emergency patients in regional and metropolitan areas in Japan

BACKGROUND

To assess the performance of pediatric extracorporeal membrane oxygenation (ECMO) centers, outcomes were compared between metropolitan and other areas.

METHODS

A retrospective cohort study was conducted at three regional centers on Kyushu Island and the largest center in the Tokyo metropolitan area of Japan. The clinical outcomes of patients of ≤15 years of age who received ECMO during 2010-2019 were investigated, targeting the survival and performance at discharge from intensive care units (ICUs), using medical charts.

RESULTS

One hundred and fifty-five patients were analyzed (regional, n = 70; metropolitan, n = 85). Survival rates at ICU discharge were similar between the two areas (64%). In regional centers, deterioration of Pediatric Cerebral Performance Category (PCPC) scores were more frequent (65.7% vs. 49.4%; p = 0.042), but survival rates and ΔPCPC scores (PCPC at ICU discharge-PCPC before admission) improved in the second half of the study period (p = 0.005 and p = 0.046, respectively). Veno-arterial ECMO (odds ratio [OR], 3.00; p < 0.03), extracorporeal cardiopulmonary resuscitation (OR, 8.98; p < 0.01), and absence of myocarditis (OR, 5.47; p < 0.01) were independent risk factors for deterioration of the PCPC score. A sub-analysis of patients with acute myocarditis (n = 51), the main indicator for ECMO, revealed a significantly higher proportion of cases with deteriorated PCPC scores in regional centers (51.9% vs. 25.0%; p = 0.049).

CONCLUSIONS

The survival rates of pediatric patients supported by ECMO in regional centers were similar to those in a metropolitan center. However, neurological outcomes must be improved, particularly in patients with acute myocarditis.

The diagnosis and treatment of pediatric clinical myocarditis in China: a multicenter retrospective study

This study aims to examine the clinical characteristics and outcomes of clinical myocarditis in pediatric patients in China. This is a multicenter retrospective study. Children diagnosed with clinical myocarditis from 20 hospitals in China and admitted between January 1, 2015, and December 30, 2021, were enrolled. The clinical myocarditis was diagnosed based on the "Diagnostic Recommendation for Myocarditis in Children (Version 2018)". The clinical data were collected from their medical records. A total of 1210 patients were finally enrolled in this study. Among them, 45.6% had a history of respiratory tract infection. An abnormal electrocardiogram was observed in 74.2% of patients. Echocardiography revealed that 32.3% of patients had a left ventricular ejection fraction of less than 50%. Cardiac MRI was performed in 4.9% of children with clinical myocarditis, of which 61% showed localized or diffuse hypersignal on T2-weighted images. Serum levels of cardiac troponin I (cTnI), creatine kinase-MB (CK-MB), and N-terminal B-type natriuretic peptide (NT-proBNP) were higher in patients with fulminant myocarditis than in patients with myocarditis, making them potential risk factors for fulminant myocarditis. Following active treatment, 12.1% of patients were cured, and 79.1% were discharged with improvement.

CONCLUSION

Clinical myocarditis in children often presents with symptoms outside the cardiovascular system. CK-MB, cTnI, and NT-proBNP are important indicators for assessing clinical myocarditis. The electrocardiogram and echocardiogram findings in children with clinical myocarditis exhibit significant variability but lack specificity. Cardiac MRI can be a useful tool for screening clinical myocarditis. Most children with clinical myocarditis have a favorable prognosis.

WHAT IS KNOWN

• Pediatric myocarditis presents complex clinical manifestations and exhibits varying degrees of severity. Children with mild myocarditis generally have a favorable prognosis, while a small number of children with critically ill myocarditis experience sudden onset, hemodynamic disorders, and fatal arrhythmias. Therefore, early diagnosis and timely treatment of myocarditis are imperative.

WHAT IS NEW

• To the best of our knowledge, this multicenter retrospective study is the largest ever reported in China, aiming to reveal the clinical characteristics and outcomes of pediatric clinical myocarditis in China. We provided an extensive analysis of the clinical characteristics, diagnosis, treatment, prognosis, and factors impacting disease severity in pediatric clinical myocarditis in China, which provides insights into the epidemiological characteristics of pediatric clinical myocarditis.

Factors affecting in-hospital mortality among pediatric patients with myocarditis treated with mechanical circulatory support

BACKGROUND

Mechanical circulatory support (MCS) is a common treatment modality for circulatory failure caused by pediatric myocarditis. Despite improvements in treatment strategy, the mortality rate of pediatric patients with myocarditis treated with MCS is still high. Identifying the factors associated with mortality among pediatric patients with myocarditis treated with MCS may help reduce the mortality rate.

METHODS

This retrospective cohort study examined the data of patients aged <16 years who were admitted to a hospital between July 2010 and March 2018 for myocarditis; the data were collected from the Diagnosis Procedure Combination database, which is a national inpatient database in Japan.

RESULTS

During the study period, 105 of the 598 patients with myocarditis were treated with MCS. We excluded seven patients who died within 24 h of admission, resulting in 98 eligible patients. The overall in-hospital mortality was 22 %. In-hospital mortality was higher among patients aged <2 years and those who received cardiopulmonary resuscitation (CPR). Multivariable logistic regression analysis showed significantly higher in-hospital mortality among patients aged <2 years old [odds ratio (OR), 6.57; 95 % confidence interval (CI), 1.89-22.87] and those who received CPR (OR, 4.70; 95 % CI, 1.51-14.63; p < 0.01).

CONCLUSION

The in-hospital mortality of pediatric patients with myocarditis treated with MCS was high, particularly of children younger than 2 years and those who received CPR.

Advancing Precision Medicine in Myocarditis: Current Status and Future Perspectives in Endomyocardial Biopsy-Based Diagnostics and Therapeutic Approaches

The diagnosis and specific and causal treatment of myocarditis and inflammatory cardiomyopathy remain a major clinical challenge. Despite the rapid development of new imaging techniques, endomyocardial biopsies remain the gold standard for accurate diagnosis of inflammatory myocardial disease. With the introduction and continued development of immunohistochemical inflammation diagnostics in combination with viral nucleic acid testing, myocarditis diagnostics have improved significantly since their introduction. Together with new technologies such as miRNA and gene expression profiling, quantification of specific immune cell markers, and determination of viral activity, diagnostic accuracy and patient prognosis will continue to improve in the future. In this review, we summarize the current knowledge on the pathogenesis and diagnosis of myocarditis and inflammatory cardiomyopathies and highlight future perspectives for more in-depth and specialized biopsy diagnostics and precision, personalized medicine approaches.

Left ventricular function changes and echocardiographic predictors in adult survivors of fulminant myocarditis treated with the Chinese protocol

Disagreement exists regarding the long-term prognosis and recovery of left ventricular (LV) function in patients with fulminant myocarditis (FM). This study reported the outcome and LV ejection fraction (EF) changes in FM treated with Chinese protocol, and assessed whether global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2-D STE) could provide additional information. This retrospective study included 46 FM adult patients who applied timely circulatory support and immunomodulatory therapy with adequate doses of both glucocorticoids and immunoglobulins as core approaches and survived after acute phase. They all presented with acute onset of cardiac symptoms < 2 weeks. LV end-diastolic dimensions, LVEF and GLS at discharge and 2-year were obtained and compared. We then performed linear regression and ROC analysis to determine independent factors to predict normalization of GLS at 2-year. At 2 years, the survival was 100% in our cohort. And the GLS improved modestly (15.40 ± 3.89% vs 17.24 ± 2.89%, P = 0.002). At two years, a proportion of patients whose LV function remained abnormal, being 22% evaluated by EF (< 55%) and higher to 37% by GLS (< 17%). Moreover, GLS at discharge but not at presentation correlated with GLS at 2-year (r = 0.402, P = 0.007). The FM adult treated with Chinese protocol have good survival and modest improvement of LV function during 2-year.

Recent Trends in Incidence and Outcomes for Acute Myocarditis in Children in the United States

Lack 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.

Clinical characteristics and mortality risk prediction model in children with acute myocarditis

BACKGROUND

Acute myocarditis (AMC) can cause poor outcomes or even death in children. We aimed to identify AMC risk factors and create a mortality prediction model for AMC in children at hospital admission.

METHODS

This was a single-center retrospective cohort study of AMC children hospitalized between January 2016 and January 2020. The demographics, clinical examinations, types of AMC, and laboratory results were collected at hospital admission. In-hospital survival or death was documented. Clinical characteristics associated with death were evaluated.

RESULTS

Among 67 children, 51 survived, and 16 died. The most common symptom was digestive disorder (67.2%). Based on the Bayesian model averaging and Hosmer-Lemeshow test, we created a final best mortality prediction model (acute myocarditis death risk score, AMCDRS) that included ten variables (male sex, fever, congestive heart failure, left-ventricular ejection fraction < 50%, pulmonary edema, ventricular tachycardia, lactic acid value > 4, fulminant myocarditis, abnormal creatine kinase-MB, and hypotension). Despite differences in the characteristics of the validation cohort, the model discrimination was only marginally lower, with an AUC of 0.781 (95% confidence interval = 0.675-0.852) compared with the derivation cohort. Model calibration likewise indicated acceptable fit (Hosmer‒Lemeshow goodness-of-fit, P¼ = 0.10).

CONCLUSIONS

Multiple factors were associated with increased mortality in children with AMC. The prediction model AMCDRS might be used at hospital admission to accurately identify AMC in children who are at an increased risk of death.

Clinical Efficacy of Creatine Phosphate Sodium and/or Vitamin C in the Treatment of Children with Viral Myocarditis: A Meta-Analysis

Background. This study performed a meta-analysis to explore the clinical efficacy of creatine phosphate sodium (CPS) and/or vitamin C for viral myocarditis (VMC) in children, to provide guidance for its clinical treatment. Methods. A literature search was performed on PubMed, Web of Science, Embase, China National Knowledge Infrastructure, and Wanfang databases to obtain published clinical randomized controlled trials (RCTs) on CPS and/or vitamin C for VMC in children, with a time span from 2013 to 2022. Relevant data was extracted and meta-analysis was performed using the statistical software Stata 16.0. Results. A total of 723 studies were retrieved and 19 studies were finally included for meta-analysis, with a total of 1,957 patients. The meta-analysis results showed that the observation group (conventional treatment + CPS and/or vitamin C) was superior to the control group (conventional treatment alone) in treatment effective rate ( $\text{OR}=3.60$ , 95% CI (2.55, 5.07), and $P<0.001$ ). Additionally, the observation group had lower levels of cardiac troponin-I (SMD = − 2.63, 95% CI (− 3.51, − 1.76), and $P<0.001$ ), creatine kinase isoenzyme ( $\text{SMD}=-2.78$ , 95% CI (− 3.53, − 2.03), and $P<0.001$ ), lactate dehydrogenase ( $\text{SMD}=-1.95$ , 95% CI (− 2.49, − 1.42), and $P<0.001$ ), aspartate aminotransferase ( $\text{SMD}=-0.87$ , 95% CI (− 1.84, 0.09), and $P=0.076$ ), tumor necrosis factor-α ( $\text{SMD}=-3.90$ , 95% CI (− 4.47, − 3.06), and $P<0.001$ ), and higher superoxide dismutase levels ( $\text{SMD}=2.48$ , 95% CI (1.64, 3.33), and $P<0.001$ ). Except aspartate aminotransferase, there were significant differences between the two groups in the other parameters. Conclusion. CPS and/or vitamin C treatment could greatly improve the treatment, protect myocardial function, and relieve inflammatory response in children with VMC.

Myocarditis in Children: Impact of Early Presentation on Disease Outcomes at a Single Tertiary Center in Saudi Arabia

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.

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.

State-of-the-Art of Endomyocardial Biopsy on Acute Myocarditis and Chronic Inflammatory Cardiomyopathy

Purpose of Review

Histologic evidence of myocardial inflammatory infiltrate not secondary to an ischemic injury is required by current diagnostic criteria to reach a definite diagnosis of myocarditis. Endomyocardial biopsy (EMB) is therefore often indicated for the diagnosis of myocarditis, although it may lack sufficient sensitivity considering the limited possibility of myocardial sampling. Improving the diagnostic yield and utility of EMB is of high priority in the fields of heart failure cardiology and myocarditis in particular. The aim of the present review is to highlight indications, strengths, and shortcomings of current EMB techniques, and discuss innovations currently being tested in ongoing clinical studies, especially in the setting of acute myocarditis and chronic inflammatory cardiomyopathy.

Recent Findings

EMB provides unique diagnostic elements and prognostic information which can effectively guide the treatment of myocarditis. Issues affecting the diagnostic performance in the setting of acute myocarditis and chronic inflammatory cardiomyopathies will be discussed in this review in the light of recent expert consensus documents on the management of these conditions and on indication to EMB. Recent innovations using electroanatomic mapping (EAM)-guided EMB and fluoroscopic-guided EMB during temporary mechanical circulatory support have improved the utility of the procedure.

Summary

EMB remains an important diagnostic test whose results need to be interpreted in the context of (1) clinical pre-test probability, (2) timing of sampling, (3) quality of sampling (4) site of sampling, (5) histologic type of myocarditis, and (6) analytic methods that are applied. Herein we will review these caveats as well as perspectives and innovations related to the use of this diagnostic tool.

Inspiration to mRNA-based COVID-19 vaccination: Serious adverse case reports with hepatitis B vaccine in real-world

OBJECTIVES

The hepatitis B vaccine comprises hepatitis B surface antigen (HBsAg) produced by transgenic yeast cells. There are few serious adverse events (SAE) reports after Hepatitis B vaccination.

METHODS

The authors searched the Chinese legal documents database for all SAE with Hepatitis B vaccination from January 2010 to January 2022.

RESULTS

All seven patients received yeast-derived recombinant hepatitis B vaccine. Three cases of myocarditis (death), 2 cases of interstitial pneumonia (death), and 2 cases of encephalitis. The mean time of onset of SAE was 8.3 ± 4.3 h after vaccination.

CONCLUSION

The mechanism of vaccine-induced myocarditis may come from immune protein reactions. Based on the experience of Hepatitis B vaccine adverse events, we present new insights into the mechanism of myocarditis caused by the COVID-19 vaccine.

Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis

OBJECTIVE

Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM).

METHODS

The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019.

RESULTS

In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%).

CONCLUSION

Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.

Update on acute myocarditis

Acute myocarditis (AM), a recent-onset inflammation of the heart, has heterogeneous clinical presentations, varying from minor symptoms to high-risk cardiac conditions with severe heart failure, refractory arrhythmias, and cardiogenic shock. AM is moving from being a definitive diagnosis based on histological evidence of inflammatory infiltrates on cardiac tissue to a working diagnosis supported by high sensitivity troponin increase in association with specific cardiac magnetic resonance imaging (CMRI) findings. Though experts still diverge between those advocating for histological definition versus those supporting a mainly clinical definition of myocarditis, in the real-world practice the diagnosis of AM has undoubtedly shifted from being mainly biopsy-based to solely CMRI-based in most of clinical scenarios. It is thus important to clearly define selected settings where EMB is a must, as information derived from histology is essential for an optimal management. As in other medical conditions, a risk-based approach should be promoted in order to identify the most severe AM cases requiring appropriate bundles of care, including early recognition, transfer to tertiary centers, aggressive circulatory supports with inotropes and mechanical devices, histologic confirmation and eventual immunosuppressive therapy. Despite improvements in recognition and treatment of AM, including a broader use of promising mechanical circulatory supports, severe forms of AM are still burdened by dismal outcomes. This review is focused on recent clinical studies and registries that shed new insights on AM. Attention will be paid to contemporary outcomes and predictors of prognosis, the emerging entity of immune checkpoint inhibitors-associated myocarditis, updated CMRI diagnostic criteria, new data on the use of temporary mechanical circulatory supports in fulminant myocarditis. The role of viruses as etiologic agents will be reviewed and a brief update on pediatric AM is also provided. Finally, we summarize a risk-based approach to AM, based on available evidence and clinical experience.

Pediatric Fulminant Myocarditis in Japan: A Retrospective Nationwide Database Study of Hospital Volume, Management Practices, and Mortality

OBJECTIVES

Pediatric fulminant myocarditis is a subset of pediatric acute myocarditis associated with critical illness. We aimed to compare mortality and other outcomes such as length of hospital stay between pediatric fulminant myocarditis and nonfulminant myocarditis. For the subgroup of patients with fulminant myocarditis, we also aimed to describe the current management practices and evaluate the impact of clinically relevant factors, including hospital case volume, on mortality.

DESIGN

Retrospective observational study using the Diagnosis Procedure Combination database from April 2012 to March 2018.

SETTING

Over 1,000 acute care hospitals in Japan.

PATIENTS

Patients with acute myocarditis less than 18 years old, including patients with fulminant myocarditis (i.e., those who received at least one of the following by day 7 of hospitalization: inotropes/vasopressors, mechanical circulatory support, or cardiopulmonary resuscitation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression analysis was conducted to investigate the association between clinically relevant factors and in-hospital mortality of patients with fulminant myocarditis. Furthermore, post hoc propensity score analyses (propensity score-adjusted, propensity score-matched, and inverse probability of treatment-weighted analyses) were performed to confirm the effect of hospital case volume on in-hospital mortality. In total, 866 pediatric patients with acute myocarditis were included, and 382 (44.1%) were categorized as fulminant myocarditis. In-hospital mortality for those with fulminant myocarditis was 24.1%. fulminant myocarditis was associated with 41.3-fold greater odds of mortality than nonfulminant myocarditis (95% CI, 14.7-115.9; p < 0.001). In the subgroup of patients with fulminant myocarditis, a higher in-hospital mortality was significantly associated with younger age (≤ 5 yr; odds ratio, 3.41; 95% CI, 1.75-6.64) and the need for either mechanical ventilation (odds ratio, 2.39; 95% CI, 1.03-5.57), cardiopulmonary resuscitation (odds ratio, 10.63; 95% CI, 5.52-20.49), or renal replacement therapy (odds ratio, 2.53; 95% CI, 1.09-5.87) by day 7. A lower in-hospital mortality rate was significantly associated with treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr; odds ratio, 0.30; 95% CI, 0.13-0.68) compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). Post hoc propensity score analyses consistently supported the primary results.

CONCLUSIONS

In-hospital mortality of pediatric fulminant myocarditis in Japan remains high. Treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr) was associated with a 70% relative reduction in odds of in-hospital mortality compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). The reasons for such differences need further study.

Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis

OBJECTIVE

Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM).

METHODS

The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019.

RESULTS

In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%).

CONCLUSION

Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.

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

BACKGROUND

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSION

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

The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis

Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.

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

ABSTRACT

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

Myocardial strain features by 2D-STE during the course of fulminant myocarditis: Correlation with characteristics by CMR and clinical implications

Myocardial strain analysis by 2D speckle tracking echocardiography could determine the left ventricular function. Our purpose is to investigate the global longitudinal strain (GLS) changes during the course of fulminant myocarditis (FM) and evaluate their correlation with cardiac magnetic resonance (CMR).Patients with clinical diagnosis of FM from June 30, 2017 to June 30, 2019 were screened prospectively. 18 survived patients (mean age 34 ± 18 years) who had two scans of transthoracic echocardiography and underwent CMR were included.All patients had severely impaired left ventricular ejection fraction and GLS value at admission that improved significantly before discharge. The patients in the healed stage revealed elevated global native T1 and T2 relaxation time and extracellular volume fraction as well, which were 1408.3 ± 88.3ms, 46.56 ± 5.23ms, and 0.35 ± 0.09, respectively. GLS from the second transthoracic echocardiography in the healed stage correlated significantly with global native T1 relaxation time (r =-0.574, P = .013) and with extracellular volume fraction (r = -0.582, P = .011), but not global native T2 relaxation time (r = -0.31, P = .211) and not with late gadolinium enhancement mass (r = 0.084, P = .743). In comparison, GLS at admission were not correlated with CMR parameters of fibrosis and oedema in the healed stage.GLS by 2D-STE may emerge as a new tool to monitor inflammatory myocardial injuries during the course of FM. FM in the acute healed stage has the presence of both chronic fibrosis and oedema which are correlated with GLS, but GLS at admission can't predict the early recovery of myocardial inflammation.

Right Ventricular Damage in COVID-19: Association Between Myocardial Injury and COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a global pandemic. It has resulted in considerable morbidity and mortality around the world. The respiratory system is the main system invaded by the virus involved in COVID-19. In addition to typical respiratory manifestations, a certain proportion of severe COVID-19 cases present with evidence of myocardial injury, which is associated with excessive mortality. With availability of an increasing amount of imaging data, right ventricular (RV) damage is prevalent in patients with COVID-19 and myocardial injury, while left ventricular damage is relatively rare and lacks specificity. The mechanisms of RV damage may be due to increased RV afterload and decreased RV contractility caused by various factors, such as acute respiratory distress syndrome, pulmonary thrombosis, direct viral injury, hypoxia, inflammatory response and autoimmune injury. RV dysfunction usually indicates a poor clinical outcome in patients with COVID-19. Timely and effective treatment is of vital importance to save patients' lives as well as improve prognosis. By use of echocardiography or cardiovascular magnetic resonance, doctors can find RV dilatation and dysfunction early. By illustrating the phenomenon of RV damage and its potential pathophysiological mechanisms, we will guide doctors to give timely medical treatments (e.g., anticoagulants, diuretics, cardiotonic), and device-assisted therapy (e.g., mechanical ventilation, extracorporeal membrane oxygenation) when necessary for these patients. In the paper, we examined the latest relevant studies to investigate the imaging features, potential mechanisms, and treatments of myocardial damage caused by COVID-19. RV damage may be an association between myocardial damage and lung injury in COVID-19. Early assessment of RV geometry and function will be helpful in aetiological determination and adjustment of treatment options.

Influenza Myocarditis: A Literature Review

Viral myocarditis is not uncommon but the role of the influenza virus in causing myocarditis is less studied. It is difficult to diagnose influenza myocarditis. Due to bacterial and viral co-infection during influenza outbreaks, it becomes more difficult to distinguish influenza myocarditis from other causes. Our article provides current information on influenza myocarditis. We did a literature search using appropriate terms and reviewed articles published by November 2020. Our study highlights the incidence of influenza myocarditis and the need to become aware of this condition, especially during epidemics and pandemics. Our study highlights that although influenza myocarditis is a rare condition, it can be fatal. There should be increased awareness about the condition. By the early diagnosis and treatment of influenza myocarditis, we can prevent fatal complications.

Clinical characteristics and treatment effects of astragalus injection in non-pediatric patients with acute fulminant myocarditis

To explore the clinical characteristics of non-pediatric patients with acute fulminant myocarditis (AFM) and evaluate the treatment effects of astragalus injection on this disease.A total of 54 AFM patients were screened out from 586 patients with acute myocarditis, admitted to the department of cardiology between January 2011 to June 2018. The demographic and clinical data, investigations, treatments, and short-term outcomes were collected and retrospectively analyzed.The mean age of the 54 AFM patients was 34 ± 16.5 years old (range: 13-70 years), including 24 (44.5%) men and 30 (55.5%) women, with a high incidence in 2 age groups: 13-19 and 40-49 years old, despite an inverse trend to the increase of age. All these cases were admitted in emergency conditions: 26 (48.1%) cardiogenic shock, 18 (33.4%) malignant arrhythmias, 8 (14.8%) severe heart failure, and 2 (3.7%) acute pericardial tamponade. Apart from first-aid measures, 37 (68.5%) patients received astragalus injection. During hospitalization, 11 (20.4%) patients died, and 4 (36.3%) of them were from astragalus group while 7 (63.7%) of them from without-astragalus group (P=0.03). Furthermore, the levels of cardiac injury biomarkers, renal function and left ventricular ejection fraction of astragalus group were significantly improved compared with those of without-astragalus group at discharge (all P < .05).Middle-aged people were also prone to AFM. And cardiac shock was the most common, while acute pericardial tamponade was a rare presentation in non-pediatric AFM patients. Astragalus was a potential adjuvant medicine for the treatment of AFM.

Complement C9 expression is associated with damaged myocardial cells in pediatric sudden death cases of fulminant myocarditis

Background

Because disease progression is so fast in sudden death of acute fulminant myocarditis, damage of myocardial cells is not evident in routine hematoxylin and eosin staining. To understand damage to myocardial cells and the mechanism of sudden death, immunohistochemical staining was performed for two forensic autopsy cases.

Case presentation

The patients were a healthy 5-year-old girl and 8-year-old boy. They suddenly died within 2 days of appearance of flu-like symptoms. An autopsy showed accumulation of yellowish-clear pericardial fluid containing fibrin deposits, fluid blood in the heart, and congestion of visceral organs. Histologically, minor necrosis or degeneration of myocardial cells with mainly lymphocytic infiltration was observed sometimes in tissue sections. Immunohistochemically, positive complement C9 staining and negative sirtuin 1 staining were found. These findings suggested wide damage of myocardial cells, even in regions with no marked changes in myocardial cells with hematoxylin and eosin staining. These areas corresponded to those with strong accumulation of lymphocytes.

Conclusions

Immunohistochemistry for complement C9 and sirtuin 1 might become a new tool for evaluating damage of myocardial cells of fulminant acute myocarditis.

Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document

Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.

Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis

Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.

Diagnosis, Evaluation, and Treatment of Myocarditis in Children

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.

Acute Myocarditis in Children: a 10-year Nationwide Study (2007-2016) based on the Health Insurance Review and Assessment Service Database in Korea

BACKGROUND AND OBJECTIVES

We performed a nationwide study to assess the incidence, treatment patterns, and outcomes of acute myocarditis in Korean children.

METHODS

The nationwide incidence, treatment patterns, and outcomes of acute myocarditis in Korean children were assessed using data between 2007 and 2016 from the Health Insurance Review and Assessment database.

RESULTS

We investigated 1,627 children during the study period. The overall incidence of acute myocarditis was 1.4 per 100,000 children in 2007 and 2.1 per 100,000 children in 2016, which indicates a significant increase in the trend over time. A bimodal age distribution was observed with a larger peak in infancy and a smaller peak in the mid-teenage years. No sex difference was observed in the incidence rate of acute myocarditis in children aged ≤5 years (373 boys vs. 366 girls); however, the incidence rate of acute myocarditis in adolescents aged ≥13 years showed significant male preponderance (482 boys vs. 152 girls). Acute fulminant myocarditis occurred in 371 children (22.8%) who needed extracorporeal membrane oxygenation and/or mechanical ventilator support. Of the 371 children with acute fulminant myocarditis, 258 (69.5%) survived. The survival rate of children with acute fulminant myocarditis remained nearly identical over the 10-year study period.

CONCLUSIONS

This was the first nationwide epidemiological study to investigate acute myocarditis in Korean children. In our view, this study would help clinicians in decision-making and planning for optimal management of acute myocarditis in children.

Swainsonine protects H9c2 cells against lipopolysaccharide-induced apoptosis and inflammatory injury via down-regulating miR-429

Pediatric myocarditis (PM) is usually related to myocardial dysfunction. Generally, 30% of PM patients will die or undergo heart transplantation. Swainsonine (SW) is a natural alkaloid and an anti-cancer substance. Our goal was to determine the roles of SW in PM in current study. H9c2 cells were pre-treated by lipopolysaccharide (LPS). Viability and apoptosis were evaluated utilizing CCK-8 assay and flow cytometry. Inflammatory cytokines' mRNA expression and production were assessed by western blot and ELISA. Western blot was utilized to distinguish apoptosis and immune-related factors expression. Sequentially, the abovementioned parameters were reassessed when miR-429 was overexpressed. LPS declined viability as well as raised apoptosis and inflammatory injury in H9c2 cells. SW alleviated apoptosis and inflammatory injury induced by LPS. MiR-429 expression was elevated by LPS and suppressed by SW. SW-induced the increasing of viability and the reduction of inflammatory injury were reversed by overexpression of miR-429. Eventually, SW inhibited p38MAPK/NF-κB pathway which activated by LPS via overexpressing miR-429. SW exerted its anti-apoptosis and anti-inflammatory function in LPS-treated H9c2 cells through p38MAPK/NF-κB pathway and down-regulation of miR-429.

Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry "MYKKE"

Myocarditis represents an important cause for acute heart failure. MYKKE, a prospective multicenter registry of pediatric patients with myocarditis, aims to gain knowledge on courses, diagnostics, and therapy of pediatric myocarditis. The role of mechanical circulatory support (MCS) in children with severe heart failure and myocarditis is unclear. The aim of this study was to determine characteristics and outcome of patients with severe heart failure requiring MCS and/or heart transplantation. The MYKKE cohort between September 2013 and 2016 was analyzed. A total of 195 patients were prospectively enrolled by 17 German hospitals. Twenty-eight patients (14%) received MCS (median 1.5 years), more frequently in the youngest age group (0-2 years) than in the older groups (P < 0.001; 2-12 and 13-18 years). In the MCS group, 50% received a VAD, 36% ECMO, and 14% both, with a survival rate of 79%. The weaning rate was 43% (12/28). Nine (32%) patients were transplanted, one had ongoing support, and six (21%) died. Histology was positive for myocarditis in 63% of the MCS group. Patients within the whole cohort with age <2 years and/or ejection fraction <30% had a significantly worse survival with high risk for MCS, transplantation, and death (P < 0.001). Myocarditis represents a life-threatening disease with an overall mortality of 4.6% in this cohort. The fulminant form more often affected the youngest, leading to significantly higher rate of MCS, transplantation, and mortality. MCS represents an important and life-saving therapeutic option in children with myocarditis with a weaning rate of 43%.

Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score

Background

The length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission.

Methods

We performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017.

Results

Overall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%).

Conclusions

Pediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0392-2) contains supplementary material, which is available to authorized users.

Role of intravenous immunoglobulin therapy in the survival rate of pediatric patients with acute myocarditis: A systematic review and meta-analysis

The treatment of pediatric myocarditis is controversial, and the benefits of intravenous immunoglobulin (IVIG) are inconclusive due to limited data. We searched studies from PubMed, MEDLINE, Embase, and Cochrane Library databases since establishment until October 1st, 2018. Thirteen studies met the inclusion criteria. We included a total of 812 patients with IVIG treatment and 592 patients without IVIG treatment. The meta-analysis showed that the survival rate in the IVIG group was higher than that in the non-IVIG group (odds ratio = 2.133, 95% confidence interval (CI): 1.32-3.43, p = 0.002). There was moderate statistical heterogeneity among the included studies (I² = 35%, p = 0.102). However, after adjustment using Duval and Tweedie's trim and fill method, the point estimate of the overall effect size was 1.40 (95% CI 0.83, 2.35), which became insignificant. Moreover, the meta-regression revealed that age (coefficient = -0.191, 95% CI (-0.398, 0.015), p = 0.069) and gender (coefficient = 0.347, 95% CI (-7.586, 8.279), p = 0.93) were not significantly related to the survival rate. This meta-analysis showed that IVIG treatment was not associated with better survival. The use of IVIG therapy in acute myocarditis in children cannot be routinely recommended based on current evidence. Further prospective and randomized controlled studies are needed to elucidate the effects of IVIG treatment.

Computational Identification of Ventricular Arrhythmia Risk in Pediatric Myocarditis

Children with myocarditis have increased risk of ventricular tachycardia (VT) due to myocardial inflammation and remodeling. There is currently no accepted method for VT risk stratification in this population. We hypothesized that personalized models developed from cardiac late gadolinium enhancement magnetic resonance imaging (LGE-MRI) could determine VT risk in patients with myocarditis using a previously-validated protocol. Personalized three-dimensional computational cardiac models were reconstructed from LGE-MRI scans of 12 patients diagnosed with myocarditis. Four patients with clinical VT and eight patients without VT were included in this retrospective analysis. In each model, we incorporated a personalized spatial distribution of fibrosis and myocardial fiber orientations. Then, VT inducibility was assessed in each model by pacing rapidly from 26 sites distributed throughout both ventricles. Sustained reentrant VT was induced from multiple pacing sites in all patients with clinical VT. In the eight patients without clinical VT, we were unable to induce sustained reentry in our simulations using rapid ventricular pacing. Application of our non-invasive approach in children with myocarditis has the potential to correctly identify those at risk for developing VT.

Corticosteroids and Intravenous Immunoglobulin in Pediatric Myocarditis: A Meta-Analysis

Background: The efficacy of corticosteroids and intravenous immunoglobulin (IVIG) in pediatric myocarditis remains controversial. Objectives: The authors performed a meta-analysis to assess the therapeutic efficacy of corticosteroids and IVIG in children with myocarditis. Methods: We retrieved the trials on corticosteroids and IVIG therapy, respectively, in pediatric myocarditis from nine databases up to December 2018. Statistical analysis was performed using Review Manager 5.3. Results: Our analysis included 8 studies and 334 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant improvement on left ventricular ejection fraction (LVEF) from 1 to 8 month-follow-up (MD = 5.17%, 95% CI = -0.26% to 10.60%, P = 0.06), and no significant improvement in death or heart transplantation incidence at the end of follow-up (OR = 1.33, 95% CI = 0.27-6.70, P = 0.73). However, children receiving IVIG revealed a statistically remarkable increase in LVEF at a follow-up over the course of 6 months to 1 year (MD = 18.91%, 95% CI = 11.74-26.08%, P < 0.00001), and a decrease in death or heart transplantation at the end of follow-up (OR = 0.31, 95% CI = 0.12-0.75, P = 0.01). Further comparisons showed that the mortality and heart transplantation rate of children with myocarditis treated with IVIG were significantly lower than those with corticosteroid therapy (t' = 11.336, P < 0.001). Conclusions: IVIG might be beneficial to improve LVEF and survival for myocarditis in children. However, the present evidence does not support corticosteroids as superior to conventional therapy in children with myocarditis. Further randomized controlled trials with a larger sample size are required.

The Clinical Features of Children With Acute Fulminant Myocarditis and the Diagnostic and Follow-Up Value of Cardiovascular Magnetic Resonance

Objective: To investigate the clinical features and the diagnostic and follow-up value of acute fulminant myocarditis (AFM) in children. Methods: A total of 20 children diagnosed with AFM admitted to our department were reviewed, and the clinical manifestations; pathogenic examination results; myocardial injury biomarkers; and electrocardiography, echocardiogram, and cardiovascular magnetic resonance (CMR) results were analyzed. Results: Twenty children with AFM, including 12 males and 8 females, aged 3-16 years, were analyzed. The initial symptoms were abdominal pain, vomiting, fatigue, syncope, and convulsions. All children had significantly increased hs-cTnT and NT-pro BNP. In addition to nonspecific ST-T changes, there were 10 cases of complete atrioventricular block, 2 cases of advanced atrioventricular block, and 1 case of ventricular tachycardia. Echocardiography showed an increase in the cardiac chamber sizes in 15 patients and a decrease in left ventricular ejection fraction (LVEF) in 17 patients. There were 16 patients with abnormal CMR findings, including 13 cases of high T2-weighted image (T2WI) signal and 14 cases of late gadolinium enhancement (LGE). In the patients who underwent CMR within 14 days of onset, the sensitivity of T2WI and LGE and the positive diagnosis rate were higher than in those who underwent CMR after 14 days, but the difference was not statistically significant. CMR was followed up in 10 patients: 7 patients returned to normal, 2 patients still had mild LGE, and 1 patient developed inflammatory dilated cardiomyopathy. All patients were treated with high-dose immunoglobulin, 11 of whom received high-dose immunoglobulin combined with glucocorticoids. Eight patients received temporary pacemakers, and 1 patient received ECMO. None of the patients died. The peak of hs-cTnT was significantly higher in the glucocorticoid group than in the unused glucocorticoid group (2853.4 ± 2217.2 and 1124.7 ± 527.3 pg/ml, respectively). Conclusion: Children with AFM have unique clinical features. Early identification and effective treatment can reduce the mortality rate and improve the prognosis. CMR is highly sensitive in the diagnosis of ARM, especially within 14 days of onset, and is a useful noninvasive imaging technique for the early identification of AFM in children. The dynamic observation and follow-up of children with AFM through CMR can guide clinical decision-making and prognosis assessment.

Pediatric Biventricular Assist Device for Myocarditis and Complicated Left Ventricular Thrombus

An 8-year-old girl presenting with fulminant myocarditis and cardiogenic shock underwent peripheral extracorporeal membrane oxygenation. She was switched to central extracorporeal membrane oxygenation because of inadequate venous drainage, and an echocardiogram showed left ventricular (LV) thrombus. She underwent removal of the LV thrombus with LV venting. An echocardiogram showed LV thrombus again 2 days later. The LV thrombus was again removed, and a biventricular assist device support was initiated to avoid further thrombus formation. The patient was completely weaned from mechanical circulatory support after 7 days. She recovered fully without any neurologic deficit.

Identification of potential pathogenic viruses in patients with acute myocarditis using next-generation sequencing

Myocarditis is an inflammatory disease of the myocardium and leads to cardiac dysfunction and heart failure. Although viral infections are considered to be the most common etiology of myocarditis, the identification of the causative virus is still challenging. Recently, next-generation sequencing (NGS) has been applied in the diagnosis of infectious diseases. The aim of the current study was to comprehensively analyze potential pathogenic microorganisms using NGS in the sera of patients with myocarditis. Twelve pediatric and five adult patients hospitalized for acute myocarditis were included. Serum samples in the acute phase were obtained and analyzed using NGS to detect pathogen-derived DNA and RNA. Viral sequence reads were detected in 7 (41%) of the 17 myocarditis patients by NGS. Among these patients, detection of Epstein-Barr virus, human parvovirus B19, torque teno virus, and respiratory syncytial virus reads by NGS was consistent with polymerase chain reaction or antigen test results in one patient each. A large number of human pegivirus reads were detected from one patient by RNA sequencing; however, its pathogenicity to human is unknown. Conversely, the number of detected virus-derived reads was small in most cases, and the pathophysiological role of these viruses remains to be clarified. No significant bacterial or fungal reads other than normal bacterial flora was detected. These data indicate that comprehensive detection of virus-derived DNA and RNA using NGS can be useful for the identification of potential pathogenic viruses in myocarditis.

The Prevalence and Findings of Subclinical Influenza-associated Cardiac Abnormalities among Japanese Patients

Objective Although life-threatening cardiac complications in influenza infection are rare, subclinical influenza-associated cardiac abnormalities may occur more frequently. We investigated the prevalence of subclinical cardiac findings. Methods After obtaining their written informed consent, 102 subjects were enrolled in the present study. The study subjects underwent a first set of examinations, which included electrocardiography (ECG), echocardiography, and the measurement of their cardiac enzyme levels. Those with one or more abnormal findings among these examinations were encouraged to undergo a repeat examination 2 weeks later. Results Among the 102 subjects enrolled, 22 (21.6%) were judged to have cardiac findings, including ST-T abnormalities, pericardial effusion, diastolic dysfunction, and cardiac enzyme elevation. Eighteen of these 20 subjects underwent a second screening at a median of 14 days later, and it was found that 11 of the 18 subjects were free from cardiac findings on this second examination. This suggested that the abnormalities were only transient and they therefore might have been associated with influenza. Approximately 20% of the influenza patients enrolled had cardiac findings, including ST-T segment abnormalities, pericardial effusion, and cardiac enzyme elevation. Conclusion Among the 102 patients who were studied, the cardiac findings were only mild and transient; however, physicians should be aware of influenza infection-associated cardiac abnormalities because such abnormalities may not be rare.

Myocarditis associated with influenza infection in five children

BACKGROUND

Myocarditis is an inflammatory condition located mainly in the myocardium. It is caused by a variety of bacterial and viral infections. Influenza is one of the most common relevant viruses that cause myocarditis.

OBJECTIVES

We attempted to share our experiences about clinical and laboratory findings, cardiac evaluation, and treatment of children with influenza myocarditis.

METHODS

This retrospective study was performed by the Department of Pediatric Infectious Diseases at the Faculty of Medicine, Hacettepe University in Turkey. The medical records of patients diagnosed with myocarditis associated with an influenza infection between January 2014 and January 2017 were systematically reviewed.

RESULTS

Vaccination seems likely to be an important protection strategy for both influenza infections and complications.

Fulminant myocarditis: Characteristics, treatment, and outcomes

Myocarditis is an inflammatory disease of the myocardium with a broad spectrum of clinical presentations, ranging from mild symptoms to severe heart failure. The course of patients with myocarditis is heterogeneous, varying from partial or full clinical recovery in few days to advanced low cardiac output syndrome requiring mechanical circulatory support or heart transplantation. Fulminant myocarditis (FM) is a peculiar clinical condition and is an acute form of myocarditis, whose main characteristic is a rapidly progressive clinical course with the need for hemodynamic support. Despite the common medical belief of the past decades, recent comprehensive data, including a recent registry that compared FM with acute non-FM, highlighted that FM has a poor inhospital outcome, often requires advanced hemodynamic support, and may result in residual left ventricular dysfunction in survivors. This review aimed to provide an updated practical definition of FM, including essentials in the diagnosis and management of the disease. Finally, the outcome of FM was critically revised according to the current published registries focusing on the topic.

Contemporary Postnatal Incidence of Acquiring Acute Myocarditis by Age 15 Years and the Outcomes From a Nationwide Birth Cohort

OBJECTIVES

Acute myocarditis can be lethal, but the incidence remains unclear because of its wide manifestation spectrum. We investigated the postnatal incidence of acute myocarditis and risk factors for morbidity and mortality.

DESIGN

Retrospective derived birth cohort study.

SETTING

Taiwan National Health Insurance Database for the period 2000-2014.

PATIENTS

Children born between 2000 and 2009 with complete postnatal medical care data for at least 5 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From among 2,150,590 live births, we identified 965 patients (54.8% male) admitted with the diagnosis of acute myocarditis, accounting for an overall incidence of 0.45/1,000. The cumulative incidence rates were 0.19/1,000, 0.38/1,000, 0.42/1,000, and 0.48/1,000 by ages 1, 5, 10, and 15 years, respectively. Male predominance was noted in infants and school age children (age group 6-14 yr). Arrhythmias, including tachyarrhythmia (4.8%) and bradyarrhythmia (1.1%), occurred in 56 patients. Extracorporeal membrane oxygenation support was provided to 62 patients (6.4%) and additional left ventricular assist devices in six of them. The mortality at discharge was 6.3%. The presence of ventricular tachyarrhythmia, bradyarrhythmia, and an onset at school age (6-14 yr) were associated with increased odds for the need for extracorporeal membrane oxygenation, which was the only predictor for mortality at discharge (hazard ratio, 7.85; 95% CI, 3.74-9.29). In patients who survived the acute myocarditis, late mortality was relatively low (36/904 = 4.0%). The overall survival of children with acute myocarditis were 90.9%, 90.3%, and 89.8% by the intervals of 1, 5, and 10 years after the myocarditis, respectively.

CONCLUSIONS

This birth cohort study determined the cumulative incidence of acute myocarditis for neonates by 15 years old to be one in 2,105. In an era of extracorporeal membrane oxygenation, the need of extracorporeal membrane oxygenation may reflect the severity of acute myocarditis and predict its outcome.

Early Prediction Model for Successful Bridge to Recovery in Patients With Fulminant Myocarditis Supported With Percutaneous Venoarterial Extracorporeal Membrane Oxygenation - Insights From the CHANGE PUMP Study

BACKGROUND

Cardiac recovery and prevention of end-organ damage are the cornerstones of establishing successful bridge to recovery (BTR) in patients with fulminant myocarditis (FM) supported with percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, the timing and method of successful BTR prediction still remain unclear. We aimed to develop a prediction model for successful BTR in patients with FM supported with percutaneous VA-ECMO.Methods and Results:This was a retrospective multicenter chart review enrolling 99 patients (52±16 years; female, 42%) with FM treated with percutaneous VA-ECMO. The S-group comprised patients who experienced percutaneous VA-ECMO decannulation and subsequent discharge (n=46), and the F-group comprised patients who either died in hospital or required conversion to other forms of mechanical circulatory support (n=53). At VA-ECMO initiation (0-h), the S-group had significantly higher left ventricular ejection fraction (LVEF) and lower aspartate aminotransferase (AST) concentration than the F-group. At 48 h, the LVEF, increase in the LVEF, and reduction of AST from 0-h were identified as independent predictors in the S-group. Finally, we developed an S-group prediction model comprising these 3 variables (area under the curve, 0.844; 95% confidence interval, 0.745-0.944).

CONCLUSIONS

We developed a model for use 48 h after VA-ECMO initiation to predict successful BTR in patients with FM.

Pediatric Cardiomyopathies

Pediatric cardiomyopathies are rare diseases with an annual incidence of 1.1 to 1.5 per 100 000. Dilated and hypertrophic cardiomyopathies are the most common; restrictive, noncompaction, and mixed cardiomyopathies occur infrequently; and arrhythmogenic right ventricular cardiomyopathy is rare. Pediatric cardiomyopathies can result from coronary artery abnormalities, tachyarrhythmias, exposure to infection or toxins, or secondary to other underlying disorders. Increasingly, the importance of genetic mutations in the pathogenesis of isolated or syndromic pediatric cardiomyopathies is becoming apparent. Pediatric cardiomyopathies often occur in the absence of comorbidities, such as atherosclerosis, hypertension, renal dysfunction, and diabetes mellitus; as a result, they offer insights into the primary pathogenesis of myocardial dysfunction. Large international registries have characterized the epidemiology, cause, and outcomes of pediatric cardiomyopathies. Although adult and pediatric cardiomyopathies have similar morphological and clinical manifestations, their outcomes differ significantly. Within 2 years of presentation, normalization of function occurs in 20% of children with dilated cardiomyopathy, and 40% die or undergo transplantation. Infants with hypertrophic cardiomyopathy have a 2-year mortality of 30%, whereas death is rare in older children. Sudden death is rare. Molecular evidence indicates that gene expression differs between adult and pediatric cardiomyopathies, suggesting that treatment response may differ as well. Clinical trials to support evidence-based treatments and the development of disease-specific therapies for pediatric cardiomyopathies are in their infancy. This compendium summarizes current knowledge of the genetic and molecular origins, clinical course, and outcomes of the most common phenotypic presentations of pediatric cardiomyopathies and highlights key areas where additional research is required.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifiers: NCT02549664 and NCT01912534.

Emerging Infections and Pertinent Infections Related to Travel for Patients with Primary Immunodeficiencies

In today's global economy and affordable vacation travel, it is increasingly important that visitors to another country and their physician be familiar with emerging infections, infections unique to a specific geographic region, and risks related to the process of travel. This is never more important than for patients with primary immunodeficiency disorders (PIDD). A recent review addressing common causes of fever in travelers provides important information for the general population Thwaites and Day (N Engl J Med 376:548-560, 2017). This review covers critical infectious and management concerns specifically related to travel for patients with PIDD. This review will discuss the context of the changing landscape of infections, highlight specific infections of concern, and profile distinct infection phenotypes in patients who are immune compromised. The organization of this review will address the environment driving emerging infections and several concerns unique to patients with PIDD. The first section addresses general considerations, the second section profiles specific infections organized according to mechanism of transmission, and the third section focuses on unique phenotypes and unique susceptibilities in patients with PIDDs. This review does not address most parasitic diseases. Reference tables provide easily accessible information on a broader range of infections than is described in the text.