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Tara S, Yamamoto T, Kanaoka K, Oka E, Shiomura R, Matsuda J, Nakata J, Miyachi H, Onoue K, Saito Y, Shimizu W, Asai K. Effects of Cardioprotective Drugs on 90-Day Mortality or Heart Transplantation in Patients With Fulminant Myocarditis. Circ Rep 2024; 6:322-332. [PMID: 39132328 PMCID: PMC11309774 DOI: 10.1253/circrep.cr-24-0059] [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: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 08/13/2024] Open
Abstract
Background Cardioprotective drugs have not been previously shown to improve the prognosis in patients with fulminant myocarditis presentation (FMP). We aimed to investigate whether cardioprotective drugs, including angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) and β-blocker, administered during hospitalization improved the prognosis in patients with FMP. Methods and Results This multicenter cohort study conducted in Japan included 755 patients with clinically diagnosed FMP. Those who died within 14 days of admission were excluded, and 588 patients (median age 53 [37-65] years and 40% female) were evaluated. The primary outcome was the composite of 90-day mortality or heart transplantation. The patients were divided into 4 groups according to whether they were administered ACEI/ARB or β-blocker during hospitalization. Administration of ACEI/ARB without β-blocker improved the overall patient outcomes (log-rank test [vs. ACEI/ARB - and β-blocker -]: ACEI/ARB + and β-blocker -, P<0.001; ACEI/ARB - and β-blocker +, P=0.256). Subsequently, a matched cohort of 146 patient pairs was generated for patients with or without ACEI/ARB administration during hospitalization. The outcome-free survival at 90 days was significantly higher in the ACEI/ARB administration group than in the non-administration group (hazard ratio 0.37; 95% confidence interval 0.19-0.71). Conclusions Administration of ACEI or ARB during hospitalization was associated with favorable outcomes in terms of 90-day mortality and heart transplantation events in patients with clinically diagnosed FMP.
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Affiliation(s)
- Shuhei Tara
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Koshiro Kanaoka
- Department of Cardiovascular Medicine, Nara Medical University Nara Japan
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center Osaka Japan
| | - Eiichiro Oka
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Reiko Shiomura
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Junya Matsuda
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Hideki Miyachi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital Tokyo Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University Nara Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University Nara Japan
- Nara Prefecture Seiwa Medical Center Nara Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
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2
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Shi X, Zhang Z, Yin F, Liu W, Wang Y, Zhou X, Xu Y, Chen X, Zhu X. Cardiac magnetic resonance imaging (MRI) for detecting acute myocardial injury of fulminant myocarditis survivors after extracorporeal membrane oxygenation (ECMO) treatment in adults. Clin Radiol 2024; 79:589-598. [PMID: 38797607 DOI: 10.1016/j.crad.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/13/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
AIMS To detect the acute myocardial injury in fulminant myocarditis (FM) survivors after extracorporeal membrane oxygenation (ECMO) and to demonstrate its significant differences from non-FM patients by cardiac magnetic resonance (CMR). MATERIALS AND METHODS This retrospective study enrolled 59 patients with acute myocarditis (AM), including 35 non-FM patients, 24 FM patients, and 54 controls. The peak value of cardiac troponin T (cTnT) was recorded. Tissue parameters, including native T1, extracellular volume (ECV), late gadolinium-enhancement (LGE)%, and T2 by CMR were assessed. RESULTS The mean age was 35 ± 14 years, and 45.8% of the population were males in the AM group. Patients had higher levels of peak cTnT, peak NT-proBNP and peak C-reactive protein in the FM group (all p<0.05). Comparing with non-FM, the values of T1-based imaging parameters were significantly higher in the FM group (all p<0.05). In contrast, no difference was observed among the two groups in terms of T2 value (p=0.707). The septal area was more frequently involved in FM survivors after ECMO treatment, both in T1 and T2-based images. In addition, the cubic relationship was the relative best fit of LGE% against logcTnT and indicated that cTnT value exceeding 300ng/L exhibited a rapid upward trend of LGE%. CONCLUSION Comparing to non-FM, higher myocardial necrosis and fibrosis but similar edema determined by T1 and T2 based imaging was found in FM survivors after ECMO treatment. Furthermore, the inter-ventricular septal area was more frequently involved by acute myocardial injury in FM survivors after ECMO treatment. In addition, LGE% showed an overall increasing trend with cTnT values elevating with rapidly increasing with cTnT exceeding 300 ng/L.
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Affiliation(s)
- X Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
| | - Z Zhang
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
| | - F Yin
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
| | - W Liu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Y Wang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - X Zhou
- MR Collaboration, Siemens Healthineers, Shanghai, China
| | - Y Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - X Chen
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
| | - X Zhu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
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Seki S, Nishibatake M, Hirono K, Ueno K. Rare pediatric case of two episodes of fulminant myocarditis and cardiac dysfunction after viral infection. J Cardiol Cases 2024; 30:39-42. [PMID: 39156210 PMCID: PMC11328687 DOI: 10.1016/j.jccase.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 08/20/2024] Open
Abstract
Myocarditis presents with a broad spectrum of clinical severity, ranging from subclinical illness to sudden death. Children with fulminant myocarditis often require inotropic or mechanical circulatory support; however, recurrent acute myocarditis is extremely rare. There is limited evidence to guide the management of recurrent acute myocarditis because the relevant literature is sparse. Here, we present a rare pediatric case of recurrent acute myocarditis. This patient experienced two episodes of fulminant myocarditis and two episodes of suspected myocarditis over an eight-year period; each episode fully resolved with preserved cardiac function. Three episodes were associated with influenza virus infection. During each episode, the electrocardiography, echocardiogram, and laboratory findings improved. Autoimmune and chronic myocarditis were not suspected because of the rapid onset of myocarditis associated with viral infection. Genetic testing by next-generation sequencing was performed; however, no underlying genetic illnesses were identified. Human leukocyte antigen genotyping was performed, and the results determined the genotype to be HLA-DQB1*0302/0303, which reports indicate might be involved in the development of myocarditis in mice or humans. The combination of these genotypes in myocardial cells may be associated with susceptibility to influenza infection or acute myocarditis. Learning objective There is little evidence regarding susceptibility to myocarditis. We present a pediatric patient who experienced two episodes of fulminant myocarditis and two episodes of suspected myocarditis associated with influenza infection and a specific human leukocyte antigen genotype. This case highlights the importance of understanding myocarditis susceptibility.
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Affiliation(s)
- Shunji Seki
- Department of Pediatrics, Kagoshima Seikyo Hospital, Kagoshima, Japan
| | | | - Keiichi Hirono
- Department of Pediatrics, Graduate School of Medicine, University of Toyama, Toyama, Japan
| | - Kentaro Ueno
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
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4
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Kobayashi Y, Hamaya T, Nagai T, Mori Y, Sato T, Tsuneta S, Wakabayashi K, Kudo K, Matsuno Y, Anzai T. Multimodal Assessment of Immunosuppressive Therapy in a Patient With Chronic Active Myocarditis 3 Months Following COVID-19 Infection. CJC Open 2024; 6:826-829. [PMID: 39022170 PMCID: PMC11250859 DOI: 10.1016/j.cjco.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/25/2024] [Indexed: 07/20/2024] Open
Affiliation(s)
- Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Takeshi Hamaya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yuki Mori
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Satonori Tsuneta
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kento Wakabayashi
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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5
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Noro S, Awaya T, Hayama H, Toyoda Y, Fujisaki J, Maetani I, Moroi M, Nakamura M. Long-term imaging analysis of a myocarditis case: Utilizing strain with echocardiography and cardiovascular magnetic resonance findings. J Cardiol Cases 2024; 29:265-268. [PMID: 38826761 PMCID: PMC11143739 DOI: 10.1016/j.jccase.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 06/04/2024] Open
Abstract
Herein, we report a case of myocarditis in a 27-year-old male with long-term follow-up using longitudinal peak systolic strain (LPSS) measurements with transthoracic echocardiography (TTE) and late gadolinium enhancement (LGE) in cardiovascular magnetic resonance imaging (CMR). On admission, a predominant decrease was observed in the LPSS in the posterolateral segments of the TTE. After a period of two weeks, the values of the LPSS observed in the posterolateral segments were still slightly reduced, which is consistent with the LGE results in CMR. After a duration of 16 months, an improvement was noted in the LPSS and LGE results in all the segments. Moreover, a time-phase discrepancy was observed in the segmental longitudinal strain curve for a period of two weeks from the onset of myocarditis. However, an improvement in the discrepancy was detected after 16 months. Learning objective Longitudinal peak systolic strain (LPSS) on transthoracic echocardiography (TTE) has predominantly focused on diagnosing the acute phase of myocarditis. Herein, LPSS was evaluated not only in the acute phase but also in the chronic phase. Furthermore, the relationship between the results of segmental LPSS and late gadolinium enhancement was documented. We would like to emphasize the usefulness of LPSS on TTE both for identifying myocarditis and as a tool for the long-term follow-up of patients.
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Affiliation(s)
- Satoe Noro
- Department of Clinical Physiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Toru Awaya
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hiromasa Hayama
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasutake Toyoda
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Jun Fujisaki
- Department of Clinical Physiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Iruru Maetani
- Department of Clinical Physiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masao Moroi
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masato Nakamura
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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6
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Kobayashi Y, Nagai T, Kamiya K, Tsuneta S, Shingu Y, Wakabayashi K, Kudo K, Matsuno Y, Wakasa S, Anzai T. Chronic Active Myocarditis After Transapical Transcatheter Aortic Valve Implantation. Circ J 2024; 88:1008. [PMID: 38644167 DOI: 10.1253/circj.cj-23-0910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Affiliation(s)
- Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Satonori Tsuneta
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University
| | - Yasushige Shingu
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | | | - Kohsuke Kudo
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University
| | | | - Satoru Wakasa
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
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7
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Saito K, Kinjo T, Goto S, Sasaki S, Tomita H. Chronic active myocarditis with spatially and temporally heterogeneous lesions causing severe heart failure and intractable atrial arrhythmia: An autopsy case report. J Cardiol Cases 2024; 29:226-230. [PMID: 39100515 PMCID: PMC11295012 DOI: 10.1016/j.jccase.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 01/24/2024] [Indexed: 08/06/2024] Open
Abstract
The pathogenesis of chronic active myocarditis remains unclear. A 65-year-old man underwent permanent pacemaker implantation for sick sinus syndrome and pulmonary vein isolation for paroxysmal atrial fibrillation. Four years later, the left ventricular ejection fraction decreased from 51 % to 35 %, and the apical left ventricular inferior wall developed akinesis. Isolated cardiac sarcoidosis was suspected; however, prednisolone and optimal medical therapy failed to improve the symptoms. Even after cardiac resynchronization therapy followed by atrioventricular junction ablation for untreatable atrial tachycardia, the patient died of heart failure eight years after referral. An autopsy revealed inflammatory cell infiltration accompanied by cardiac myocytolysis in both atria and ventricles. He was diagnosed with chronic active myocarditis based on pathological findings and a persistent increase in the blood high-sensitivity cardiac troponin levels before death. The myocardium around the sinus node showed extensive and severe fibrosis with mild inflammation, suggesting a chronic inflammatory phase. In contrast, the left atrium and both ventricles showed active myocardial inflammation with fibrosis, suggesting a persistently active inflammatory phase. This case demonstrated that atrial inflammation caused intractable atrial arrhythmia, while ventricular inflammation led to biventricular heart failure, and highlighted the presence of spatially and temporally heterogeneous inflammation in chronic active myocarditis. Learning objective We describe a case of chronic active myocarditis with spatially and temporally heterogeneous lesions throughout the four cardiac chambers. Inflammatory cell infiltration was observed in both atria and ventricles. Extensive fibrosis replaced the myocardium around the sinus node, suggesting a chronic phase. The left atrium and ventricles showed active inflammation, suggesting an active phase. Atrial and ventricular inflammation led to atrial arrhythmia and heart failure, respectively.
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Affiliation(s)
- Kazumasa Saito
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shintaro Goto
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Sasaki
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Cardiac Remote Management System, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Cardiac Remote Management System, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of the Advanced Therapeutics for Cardiovascular Diseases, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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8
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Yakhshimurodov U, Yamashita K, Kawamura T, Kawamura M, Miyagawa S. Paradigm shift in myocarditis treatment. J Cardiol 2024; 83:201-210. [PMID: 37597837 DOI: 10.1016/j.jjcc.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
Although most cases of myocarditis are self-limiting with a gradual improvement in cardiac function, the involvement of myocarditis in sudden cardiac death among children and young adults remains substantial, with rates of 3-17 % and 8.6-12 %, respectively. Moreover, the risk of developing chronic dilated cardiomyopathy ranges from 21 % to 30 % in all cases confirmed by biopsy. Current therapeutic strategies for myocarditis and its complications range from standard supportive care for heart failure and arrhythmias to etiologically oriented, case-based therapeutic options. For example, immunosuppression is indicated only in certain forms of acute myocarditis with clinical or endomyocardial biopsy evidence of immune checkpoint inhibitor-induced myocarditis and autoimmune diseases, including giant cell myocarditis, eosinophilic myocarditis, vasculitis, or cardiac sarcoidosis. However, our views on myocarditis treatment have changed considerably over the past two decades, thanks to the emergence of regenerative cells/tissues as well as drug and gene delivery systems. Cell-based therapies are now growing in popularity in any field of medicine. Studies evaluating the therapeutic efficacy of different stem cells in the treatment of acute myocarditis and its chronic complications have shown that although the experimental characteristics varied from study to study, in general, these strategies reduced inflammation and myocardial fibrosis while preventing myocarditis-induced systolic dysfunction and adverse remodeling in animal models.
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Affiliation(s)
- Ulugbek Yakhshimurodov
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kizuku Yamashita
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masashi Kawamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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9
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Panagiotides NG, Poledniczek M, Andreas M, Hülsmann M, Kocher AA, Kopp CW, Piechota-Polanczyk A, Weidenhammer A, Pavo N, Wadowski PP. Myocardial Oedema as a Consequence of Viral Infection and Persistence-A Narrative Review with Focus on COVID-19 and Post COVID Sequelae. Viruses 2024; 16:121. [PMID: 38257821 PMCID: PMC10818479 DOI: 10.3390/v16010121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Microvascular integrity is a critical factor in myocardial fluid homeostasis. The subtle equilibrium between capillary filtration and lymphatic fluid removal is disturbed during pathological processes leading to inflammation, but also in hypoxia or due to alterations in vascular perfusion and coagulability. The degradation of the glycocalyx as the main component of the endothelial filtration barrier as well as pericyte disintegration results in the accumulation of interstitial and intracellular water. Moreover, lymphatic dysfunction evokes an increase in metabolic waste products, cytokines and inflammatory cells in the interstitial space contributing to myocardial oedema formation. This leads to myocardial stiffness and impaired contractility, eventually resulting in cardiomyocyte apoptosis, myocardial remodelling and fibrosis. The following article reviews pathophysiological inflammatory processes leading to myocardial oedema including myocarditis, ischaemia-reperfusion injury and viral infections with a special focus on the pathomechanisms evoked by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In addition, clinical implications including potential long-term effects due to viral persistence (long COVID), as well as treatment options, are discussed.
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Affiliation(s)
- Noel G. Panagiotides
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.A.); (A.A.K.)
| | - Martin Hülsmann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Alfred A. Kocher
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.A.); (A.A.K.)
| | - Christoph W. Kopp
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | | | - Annika Weidenhammer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Noemi Pavo
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Patricia P. Wadowski
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
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10
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Uehara H, Taguchi D, Osanai T, Oe Y, Yoshimura T, Yashiro S, Gunji T, Okuyama M. Naphazoline intoxication with transient QT prolongation and acute myocardial injury. J Cardiol Cases 2024; 29:11-14. [PMID: 38188313 PMCID: PMC10770086 DOI: 10.1016/j.jccase.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/28/2023] [Accepted: 08/23/2023] [Indexed: 01/09/2024] Open
Abstract
A 27-year-old Japanese woman with a history of depression and an eating disorder presented to our emergency department with a chief complaint of generalized weakness. Electrocardiography showed prominent QT prolongation with multiple ventricular contractions. Chest X-ray plain computed tomography revealed pulmonary edema. Echocardiography showed decreased left ventricular systolic function. Suspecting acute myocarditis, we performed a myocardial biopsy from the right ventricular septum. The biopsy histology revealed extensive myocardial fibrosis and a very mild inflammatory cell infiltrate. In an additional detailed medical interview, the patient admitted that she had consumed three bottles of a first-aid liquid containing naphazoline approximately ~12 h before her presentation, in a suicide attempt. Her QTc and left ventricular ejection fraction improved during hospitalization. Learning objective Acute drug intoxication can cause QT prolongation and ventricular arrhythmias, cardiomyopathy, and pulmonary edema. When acute QT prolongation, myocardial damage, and pulmonary edema are seen (suggesting acute myocarditis), naphazoline intoxication should be investigated in the differential diagnosis.
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Affiliation(s)
- Hiroki Uehara
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Dai Taguchi
- Department of Emergency, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Toshiaki Osanai
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Yutaro Oe
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Takaki Yoshimura
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | | | - Takahiro Gunji
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Masaki Okuyama
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
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11
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Shibata N, Kondo T, Okumura T, Imaizumi T, Dohi K, Izawa H, Ohte N, Amano T, Murohara T. Clinical Value of Troponin Levels to Cardiac Function and Prognosis in Patients with Fulminant Myocarditis. Int Heart J 2024; 65:218-229. [PMID: 38556333 DOI: 10.1536/ihj.23-589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Troponin (Tn) is a biomarker related to myocardial necrosis and is elevated in patients with myocarditis. This study aimed to investigate the association between cardiac Tn levels and the course of cardiac function, and prognosis in patients with fulminant myocarditis (FM) receiving percutaneous mechanical circulatory support (MCS).We used data from a multicenter retrospective registry, CHANGE PUMP 2, which included 216 patients with FM who required MCS. Among them, 141 patients whose Tn levels were available were analyzed. The patients were divided into low and high Tn groups according to the median values of TnT and TnI.The median age was 54 years, and 59.6% were male. The TnT and TnI on day 1 (at MCS initiation) were 3.8 (1.4-10.0) and 21.4 (8.4-68.8) ng/mL. While the left ventricular ejection fraction (LVEF) was similar on day 1 (25.0% versus 24.5%), the low Tn group showed better LVEF improvement on day 7 than the high Tn group (45.0% versus 25.3%, P < 0.001). LVEF at 1 year after admission was higher in the low Tn group (65.0% versus 59.7%, P = 0.039). The low Tn group had a better 90-day composite endpoint in death, durable left ventricular assist device implantation, and heart transplantation compared to the high Tn group (hazard ratio 0.47, 95% CI 0.23-0.95).Tn levels were associated with short- and long-term cardiac recovery and adverse outcomes in patients with FM receiving MCS due to cardiogenic shock.
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Affiliation(s)
- Naoki Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine
- Department of Advanced Medicine, Nagoya University Hospital
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University Hospital
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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12
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Nakamura M, Kitagawa A, Tamura Y, Mineo E, Takanashi M, Honda T, Shikata F, Hirata Y, Miyaji K, Ishikura K. Successful treatment of fulminant myocarditis due to COVID-19 in a 5-year-old girl. J Cardiol Cases 2023; 28:233-235. [PMID: 38126050 PMCID: PMC10730277 DOI: 10.1016/j.jccase.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/14/2023] [Accepted: 08/02/2023] [Indexed: 12/23/2023] Open
Abstract
Reports of acute myocarditis are increasing due to the worldwide spread of coronavirus disease 2019 (COVID-19). We report a case of a 5-year-old girl with fulminant myocarditis caused by COVID-19, who was successfully treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The unvaccinated patient had developed fever 1 week before attending our hospital and was "presumptive positive" for COVID-19 based on the surrounding infectious situation. The fever resolved, but the day before the visit, abdominal pain appeared. The patient visited her previous physician with vomiting as the main complaint. She was transferred to our hospital due to impaired consciousness and bradycardia, with a heart rate of 40 beats/min. Immediately after transfer, she was diagnosed with complete atrioventricular (AV) block and was scheduled to undergo percutaneous pacing lead insertion. However, the patient had ventricular tachycardia, AV block and hypotension intraoperatively and required cardiopulmonary resuscitation. The patient was in an extremely unstable circulatory state, and VA-ECMO was urgently introduced. After multidisciplinary treatment for acute myocarditis, waiting for an improvement in AV block, and recovery of cardiac function, the patient was weaned from VA-ECMO on the eighth day after admission. The patient was discharged with no cardiac or neurologic sequelae. Learning objective The rapid introduction of veno-arterial extracorporeal membrane oxygenation for fulminant myocarditis caused by coronavirus disease 2019 (COVID-19) in young children is extremely effective. Vaccination may be important for preventing infection with COVID-19 and avoiding severe complications.
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Affiliation(s)
- Maki Nakamura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Atsushi Kitagawa
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuhei Tamura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Eri Mineo
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Manabu Takanashi
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takashi Honda
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoichiro Hirata
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
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13
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Lee HJ, Kim IC. Who Can Stop This Fire? Korean Circ J 2023; 53:811-812. [PMID: 38111260 PMCID: PMC10751186 DOI: 10.4070/kcj.2023.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/12/2023] [Indexed: 12/20/2023] Open
Affiliation(s)
- Hee Jeong Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea.
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14
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Kinoshita M, Higashi K, Takaoka H, Sakai T, Murayama D, Uchikawa H, Kanaeda T, Nishikawa Y, Aoki S, Yashima S, Suzuki K, Yoshida K, Sasaki H, Suzuki-Eguchi N, Daimon M, Kobayashi Y. Cardiac Magnetic Resonance Imaging Is Useful for Follow-up of Extremely Rare Pediatric COVID-19 Fulminant Myocarditis. Circ J 2023; 87:1843. [PMID: 37940599 DOI: 10.1253/circj.cj-23-0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Affiliation(s)
- Makiko Kinoshita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | | | - Hiroyuki Takaoka
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
- Department of Cardiology, Eastern Chiba Medical Center
| | | | | | | | | | - Yusei Nishikawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Shuhei Aoki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
- Department of Cardiology, Eastern Chiba Medical Center
| | - Satomi Yashima
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
- Department of Cardiology, Eastern Chiba Medical Center
| | - Katsuya Suzuki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Kazuki Yoshida
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Haruka Sasaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Noriko Suzuki-Eguchi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
- Department of Cardiology, Eastern Chiba Medical Center
| | - Michiko Daimon
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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15
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Lasica R, Djukanovic L, Savic L, Krljanac G, Zdravkovic M, Ristic M, Lasica A, Asanin M, Ristic A. Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment. Diagnostics (Basel) 2023; 13:3073. [PMID: 37835816 PMCID: PMC10572782 DOI: 10.3390/diagnostics13193073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Although the frequency of myocarditis in the general population is very difficult to accurately determine due to the large number of asymptomatic cases, the incidence of this disease is increasing significantly due to better defined criteria for diagnosis and the development of modern diagnostic methods. The multitude of different etiological factors, the diversity of the clinical picture, and the variability of the diagnostic findings make this disease often demanding both for the selection of the diagnostic modality and for the proper therapeutic approach. The previously known most common viral etiology of this disease is today overshadowed by new findings based on immune-mediated processes, associated with diseases that in their natural course can lead to myocardial involvement, as well as the iatrogenic cause of myocarditis, which is due to use of immune checkpoint inhibitors in the treatment of cancer patients. Suspecting that a patient with polymorphic and non-specific clinical signs and symptoms, such as changes in ECG and echocardiography readings, has myocarditis is the starting point in the diagnostic algorithm. Cardio magnetic resonance imaging is non-invasive and is the gold standard for diagnosis and clinical follow-up of these patients. Endomyocardial biopsy as an invasive method is the diagnostic choice in life-threatening cases with suspicion of fulminant myocarditis where the diagnosis has not yet established or there is no adequate response to the applied therapeutic regimen. The treatment of myocarditis is increasingly demanding and includes conservative methods of treating heart failure, immunomodulatory and immunospressive therapy, methods of mechanical circulatory support, and heart transplantation. The goal of developing new diagnostic and therapeutic methods is to reduce mortality from this complex disease, which is still high.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Gordana Krljanac
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Marija Zdravkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Medical Center Bezanijska Kosa, 11000 Belgrade, Serbia
| | - Marko Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | | | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Arsen Ristic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
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