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Giordani AS, Baritussio A, Vicenzetto C, Peloso-Cattini MG, Pontara E, Bison E, Fraccaro C, Basso C, Iliceto S, Marcolongo R, Caforio ALP. Fulminant Myocarditis: When One Size Does Not Fit All - A Critical Review of the Literature. Eur Cardiol 2023; 18:e15. [PMID: 37405349 PMCID: PMC10316338 DOI: 10.15420/ecr.2022.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/12/2022] [Indexed: 07/06/2023] Open
Abstract
Fulminant myocarditis, rather than being a distinct form of myocarditis, is instead a peculiar clinical presentation of the disease. The definition of fulminant myocarditis has varied greatly in the last 20 years, leading to conflicting reports on prognosis and treatment strategies, mainly because of varied inclusion criteria in different studies. The main conclusion of this review is that fulminant myocarditis may be due to different histotypes and aetiologies that can be diagnosed only by endomyocardial biopsy and managed by aetiology-directed treatment. This life-threatening presentation requires rapid, targeted management both in the short term (mechanical circulatory support, inotropic and antiarrhythmic treatment and endomyocardial biopsy) and in the long term (including prolonged follow-up). Fulminant presentation has also recently been identified as a risk factor for worsened prognosis, even long after the resolution of the acute phase of myocarditis.
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Affiliation(s)
- Andrea Silvio Giordani
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Anna Baritussio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Cristina Vicenzetto
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Maria Grazia Peloso-Cattini
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Elena Pontara
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Elisa Bison
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Chiara Fraccaro
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Sabino Iliceto
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Renzo Marcolongo
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
| | - Alida Linda Patrizia Caforio
- Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua and Azienda Ospedale Università di PadovaPadua, Italy
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Amraotkar AR, Pachika A, Grubb KJ, DeFilippis AP. Rapid Extracorporeal Membrane Oxygenation Overcomes Fulminant Myocarditis Induced by 5‑Fluorouracil. Tex Heart Inst J 2016; 43:178-82. [PMID: 27127440 DOI: 10.14503/thij-15-5100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fulminant myocarditis is a rare but potentially life-threatening illness caused by 5-fluorouracil cardiotoxicity. Data supporting the use of extracorporeal membrane oxygenation for the treatment of fulminant myocarditis are limited. A 49-year-old, previously healthy white man, recently diagnosed with anal squamous cell carcinoma, developed severe chest pain hours after completing his first 96-hour intravenous 5-fluorouracil treatment. Over a period of 3 days from onset of symptoms, the patient developed cardiogenic shock secondary to fulminant myocarditis induced by 5-fluorouracil cardiotoxicity. This required emergency initiation of extracorporeal membrane oxygenation. The patient's systolic function recovered by day 5, and on the 17th day he was discharged in hemodynamically stable condition, without symptoms of heart failure. This case shows the importance of prompt recognition of cardiogenic shock secondary to 5-fluorouracil-induced myocarditis and how the immediate initiation of extracorporeal membrane oxygenation can restore adequate tissue perfusion, leading to myocardial recovery and ultimately the survival of the patient.
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Stefanovski D, Walfisch A, Kedev S, Tager S. Isolated right coronary lesion and anterolateral papillary muscle rupture--case report and review of the literature. J Cardiothorac Surg 2012; 7:75. [PMID: 22898299 PMCID: PMC3441214 DOI: 10.1186/1749-8090-7-75] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 07/17/2012] [Indexed: 11/10/2022] Open
Abstract
Ischemic rupture of the anterolateral papillary muscle is uncommon due to its dual blood supply. It usually follows an ischemic event involving branches of the left circumflex or left anterior descending arteries. We present a case of a patient admitted with an acute inferior wall myocardial infarction and an isolated distal right coronary artery occlusion. Acute mitral regurgitation with rupture of the anterolateral papillary muscle was diagnosed on the fifth post-infarction day. The patient underwent mitral valve replacement and coronary artery bypass grafting to the posterior descending artery. We conclude that anterolateral papillary muscle rupture may also result from an isolated right coronary lesion.
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Affiliation(s)
- Dime Stefanovski
- Cardiac Surgery Department, ACIBADEM Sistina Clinical Center, Skopje, Macedonia
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4
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Long-term follow-up on cardiac function following fulminant myocarditis requiring percutaneous extracorporeal cardiopulmonary support. Heart Vessels 2011; 28:86-90. [DOI: 10.1007/s00380-011-0211-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 11/11/2011] [Indexed: 10/14/2022]
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Ichikawa R, Sumitomo N, Komori A, Abe Y, Nakamura T, Fukuhara J, Matsumura M, Miyashita M, Kanamaru H, Ayusawa M, Mugishima H. The follow-up evaluation of electrocardiogram and arrhythmias in children with fulminant myocarditis. Circ J 2011; 75:932-8. [PMID: 21343655 DOI: 10.1253/circj.cj-10-0918] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fulminant myocarditis involves various serious arrhythmias that sometimes have lethal consequences. The purpose of the present study was to investigate the electrocardiogram findings, arrhythmogenicity and abnormalities of the cardiac conduction system in children with fulminant myocarditis. METHODS AND RESULTS Between 1999 and 2008, 7 consecutive patients (mean age: 7 years) who suffered from fulminant myocarditis were included in the study. A 12-lead electrocardiogram, Holter monitoring and signal-averaged electrocardiograms were performed and compared between the acute, convalescent, and recovery phases in the 4 surviving patients. Also, electrophysiologic assessment was carried out during the convalescent phase. Five out of 7 patients developed complete atrioventricular block, 3 developed ventricular tachycardia, 2 had cardiac arrest, 2 developed sinus tachycardia, 1 developed ventricular fibrillation, 1 had advanced atrioventricular block, and 1 developed sick sinus syndrome. Among the surviving patients, all arrhythmias resolved during the convalescent and remote phases. No atrial or ventricular arrhythmias were induced in any patients during the programmed stimulation study. In the convalescent phase, no arrhythmias could be induced and there were no signs of any conduction abnormalities on electrophysiological assessment. CONCLUSIONS Close follow-up should be performed to observe for the occurrence of any new arrhythmias and/or a decrease in cardiac function in children with fulminant myocarditis.
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Affiliation(s)
- Rie Ichikawa
- Department of Pediatrics and Child Health, Nihon University, School of Medicine, Tokyo, Japan
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Kim JC, Shim JK, An J, Lee JW, Kim DH, Kwak YL. Management of cardiogenic shock during cardiac surgery with long-term use of percutaneous cardiopulmonary support - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.5.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jong Chan Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jiwon An
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Woo Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hee Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
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7
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Nichol G, Karmy-Jones R, Salerno C, Cantore L, Becker L. Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states. Resuscitation 2006; 70:381-94. [PMID: 16828957 DOI: 10.1016/j.resuscitation.2006.01.018] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Revised: 01/03/2006] [Accepted: 01/03/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiogenic shock and cardiac arrest are common, lethal, debilitating and costly. Percutaneous cardiopulmonary bypass is an innovative strategy for treating these disorders that consists of rapid initiation of cardiopulmonary bypass and extracorporeal maintenance of circulation until restoration of an effective cardiac output. Multiple case reports suggest that percutaneous bypass is efficacious in patients with these disorders but these experiences have not been collated. Therefore, we have reviewed systematically the published experience with percutaneous bypass in patients with cardiogenic shock or cardiac arrest. OBJECTIVES The objectives were to describe the proportion of patients with cardiogenic shock or cardiac arrest who achieved restoration of spontaneous circulation or survival to discharge with percutaneous bypass. A secondary objective was to describe adverse effects associated with percutaneous bypass, if feasible. DESIGN Articles were identified by using a comprehensive search of English-language MEDLINE from 1966 to September 2005. PATIENTS Individuals in cardiogenic shock or cardiac arrest. INTERVENTIONS Percutaneous cardiopulmonary bypass. ANALYSIS Effects were summarized as inverse-variance weighted means, standard errors, median and interquartile range. RESULTS Included were 85 studies of 1494 patients with cardiogenic shock, cardiac arrest or both. Studies were case reports, case-series or case-control studies of heterogeneous interventions in heterogeneous patients. The proportion of patients weaned was mean, 76.8+/-4.2%, and median, 66.0% (IQR 50%, 100%). The proportion of patients who survived to discharge was mean, 47.4+/-4.5%, and median 40.0% (IQR 20%, 75%). Fifty-two studies included 533 patients in cardiogenic shock. The proportion of patients who survived to discharge was mean, 51.6+/-6.5%, and median 38.5% (IQR 23.4%, 76.3%). Fifty-four studies included 675 patients in cardiac arrest. The proportion of patients who survived to discharge was mean, 44.9+/-6.7%, and median, 42.3% (IQR 15.4%, 75%). Five studies with 286 subjects had both patients with cardiogenic shock or cardiac arrest. CONCLUSIONS Percutaneous bypass is an efficacious intervention in patients with cardiac arrest or cardiogenic shock. Adequately-powered experimental studies of current percutaneous bypass technologies are required to demonstrate whether it is safe, effective and cost-effective.
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Affiliation(s)
- Graham Nichol
- University of Washington, Harborview Center for Prehospital Emergency Care, Box 359727, 325 Ninth Ave., Seattle, WA 98104, USA.
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9
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Minami H, Mukohara N, Obo H, Yoshida M, Nakagiri K, Hanada T, Maruo A, Matsuhisa H, Morimoto N, Shida T. Papillary muscle rupture following acute myocardial infarction. ACTA ACUST UNITED AC 2004; 52:367-71. [PMID: 15384710 DOI: 10.1007/s11748-004-0012-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. SUBJECTS AND METHODS Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. RESULTS The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. CONCLUSION Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.
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Affiliation(s)
- Hiroya Minami
- Department of Cardiovascular Surgery, Himeji Cardiovascular Center, Himeji, Hyogo, Japan
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10
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Maejima Y, Yasu T, Kubo N, Kawahito K, Omura N, Katsuki T, Tsukamoto Y, Sugawara Y, Hashimoto S, Tsuruya Y, Hirahara T, Takagi Y, Kobayashi N, Funayama H, Ikeda N, Ishida T, Fujii M, Ino T, Saito M. Long-Term Prognosis of Fulminant Myocarditis Rescued by Percutaneous Cardiopulmonary Support Device. Circ J 2004; 68:829-33. [PMID: 15329503 DOI: 10.1253/circj.68.829] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The long-term prognosis and cardiac function of fulminant myocarditis treated with percutaneous cardiopulmonary support (PCPS) was compared with the outcome of those not treated with PCPS. METHODS AND RESULTS From 1991 to 2000, 14 patients with fulminant myocarditis (left ventricle ejection fraction (LVEF) < or =40%) were admitted to hospital. PCPS was necessary for treatment of shock in 8 (PCPS group), but not for the remaining 6 patients (non-PCPS group). In the PCPS group, 6 patients (75%) survived the critical phase and did not have any cardiac problems after discharge (range of follow-up period, 1.4-6.0 years). All patients in the non-PCPS group survived the acute phase; 1 patient had congestive heart failure 1.5 years after discharge, and another died from malignancy (follow-up period range, 2.2-9.4 years). Although the left ventricular ejection fraction (LVEF) of the PCPS group was significantly lower than that of the non-PCPS group in the acute phase, there was no significant difference in LVEF between the 2 groups in the chronic phase. CONCLUSION Patients who survive the acute phase crisis of acute myocarditis have a favorable long-term survival rate, whether or not mechanical support is used.
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Affiliation(s)
- Yasuhiro Maejima
- The Division of Cardiovascular Surgery, Omiya Medical Center, Jichi Medical School, Amanuma, Omiya, Japan
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Ikeda N, Yasu T, Kubo N, Hirahara T, Sugawara Y, Kobayashi N, Hashimoto S, Tsuruya Y, Fujii M, Saito M. Effect of Reperfusion Therapy on Cardiac Rupture After Myocardial Infarction in Japanese. Circ J 2004; 68:422-6. [PMID: 15118282 DOI: 10.1253/circj.68.422] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiac rupture after acute myocardial infarction (AMI) is unpredictable and almost always fatal, so the present study reviewed all the clinical characteristics of patients with cardiac rupture to determine if its occurrence can be predicted. METHODS AND RESULTS The clinical characteristics of 1,296 consecutive AMI patients from January 1992 to February 2002 were retrospectively evaluated using multi-logistic analysis. Cardiac rupture occurred in 45 patients (3.5%), comprising left ventricular free wall rupture (n=23), ventricular septal perforation (n=20) and papillary muscle rupture (n=2). Early-phase rupture (within 72 h after AMI onset) was associated with anterior infarction. Of the 45 patients who experienced ruptures, 24 (53.3%) survived to discharge; 21 (46.6%) of the 45 ruptures occurred after admission. Successful reperfusion therapy was performed within 24 h for 840 patients. The incidence of rupture was significantly lower for reperfused patients than for non-reperfused patients (0.6% vs 3.5%, respectively; p<0.01). Peak C-reactive protein concentration was a reliable predictor of late-phase rupture (p=0.01), but not of early-phase rupture. CONCLUSIONS Reperfusion therapy appears to aid in the prevention of cardiac rupture, especially late-phase rupture.
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Affiliation(s)
- Nahoko Ikeda
- Cardiovascular Division, First Department of Integrated Medicine, Omiya Medical Center, Jichi Medical School, Saitama, Japan
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Wheeler DS, Kooy NW. A formidable challenge: the diagnosis and treatment of viral myocarditis in children. Crit Care Clin 2003; 19:365-91. [PMID: 12848311 DOI: 10.1016/s0749-0704(03)00006-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
It is generally well accepted that one third of patients with viral myocarditis experience a complete recovery of normal cardiac function, one third improve clinically but show residual cardiac dysfunction, and one third experience chronic heart failure and die or require heart transplantation. It is hoped that a better understanding of the underlying cause and pathogenesis of this disease will increase the number of patients who experience a complete recovery. New advances in both the diagnosis and treatment of viral myocarditis continue to enter clinical practice at a rapid pace, and it is likely that a genomic approach to the diagnostic evaluation and treatment of this disease will become possible in the near future. Viral myocarditis, however, will remain a significant diagnosticand therapeutic challenge to both physicians and scientists alike.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Shioji K, Matsuura Y, Iwase T, Kitaguchi S, Nakamura H, Yodoi J, Hashimoto T, Kawai C, Kishimoto C. Successful immunoglobulin treatment for fulminant myocarditis and serial analysis of serum thioredoxin: a case report. Circ J 2002; 66:977-80. [PMID: 12381097 DOI: 10.1253/circj.66.977] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 31-year-old woman suspected to have acute myocarditis was admitted to hospital and was managed with intra-aortic balloon pumping and a percutaneous cardiopulmonary support system because of sustained ventricular tachycardia. After immunoglobulin treatment, cardiac function and systematic inflammation were improved. The left ventricular endomyocardial biopsy revealed massive necrosis and degeneration of myocardial cells, and extensive infiltration of inflammatory cells. The clinicopathology of this patient was thought to be fulminant myocarditis. Serial serum thioredoxin (TRX) analysis showed that the serum level was high during the acute phase, and decreased during the chronic phase. Immunohistochemistry for TRX in the biopsy samples showed that inflammatory cells and cardiomyocytes were positively stained.
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Affiliation(s)
- Keisuke Shioji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan
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Wada H, Yasu T, Murata S, Ohta M, Kubo N, Fujii M, Kuroki M, Kawakami M, Saito M. Rupture of the anterolateral papillary muscle caused by a single diagonal branch obstruction. Circ J 2002; 66:872-3. [PMID: 12224830 DOI: 10.1253/circj.66.872] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This report presents the first case of anterolateral papillary muscle rupture caused by a diagonal branch occlusion only. Although the patient was in shock on admission, he was successfully treated by emergency surgery after hemodynamic stabilization by a percutaneous cardiopulmonary support system. This case implies that the anterolateral papillary muscle has a single blood supply and that it can rupture by an occlusion of only one diagonal branch even after balloon angioplasty.
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Affiliation(s)
- Hiroshi Wada
- Department of Integrated Medicine 1, Omiya Medical Center, Jichii Medical School, Saitama, Japan
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15
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Abstract
Percutaneous cardiopulmonary support systems (PCPS) are compact, battery-powered, portable heart-lung machines that can be implemented rapidly in any area of the hospital using thin-walled cannulae inserted via the femoral vessels. PCPS provides temporary circulatory support by actively aspirating blood from the patient's venous system using a centrifugal pump and hollow fiber membrane oxygenator for gas exchange. A review of clinical reports has delineated several indications for emergent applications, with the most frequent being cardiac arrest (CA) or cardiogenic shock (CS). Survival is more likely in patients with CS (40%) compared to CA (21%). Implementation of PCPS after unwitnessed CA or cardiopulmonary resuscitation > 30 min yields a patient survival rate of < 10%. The likelihood of patient survival after emergent PCPS is most often related to the patient undergoing a definitive anatomic surgical repair such as coronary artery bypass or pulmonary embolectomy. If the need for circulatory support extends beyond 6 h, conversion to conventional long-term extracorporeal membrane oxygenation or a ventricular assist device is recommended.
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Affiliation(s)
- Mark Kurusz
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0528, USA.
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Aoyama N, Izumi T, Hiramori K, Isobe M, Kawana M, Hiroe M, Hishida H, Kitaura Y, Imaizumi T. National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee). Circ J 2002; 66:133-44. [PMID: 11999637 DOI: 10.1253/circj.66.133] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although fulminant myocarditis is known as a fatal disease, patients have been able to recover and return to normal life with the help of mechanical cardiopulmonary support. However, therapeutic guidelines for using percutaneous cardiopulmonary support (PCPS) for fulminant myocarditis have not been established, and the clinical course and long-term prognosis of such patients are still controversial issues. The present national survey considered the current situation of patients as the basis for proposing therapeutic guidelines. Thirty of 52 patients (57.7%) survived and returned to social life. Important factors concerning the prognosis were the severity and grade of cardiac and renal dysfunction, the adjusted support flow rate to enable recovery from circulatory failure, and prevention of circulatory disturbances of the legs and multiple organ failure directly associated with PCPS. With regard to the long-term prognosis of patients treated with PCPS, the readmission rate was 10%, the exacerbation rate was 3.3%, and mortality was 10% during the average follow-up period of 962 days. Optimal management of the mechanical cardiopulmonary support and curative treatment for the myocarditis further improve the outcome of this disease.
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Affiliation(s)
- Naoyoshi Aoyama
- Department of Internal Medicine and Cardiology, Kitasato University School of Medicine, Sagamihara, Japan
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Yukiiri K, Mizushige K, Ueda T, Nanba T, Tanimoto K, Wada Y, Takagi Y, Ohmori K, Kohno M. Fulminant myocarditis in polymyositis. JAPANESE CIRCULATION JOURNAL 2001; 65:991-3. [PMID: 11716253 DOI: 10.1253/jcj.65.991] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac involvement in patients with polymyositis is usually asymptomatic and associated with a mild clinical course. A female patient with muscle weakness and cardiogenic shock, who was diagnosed with polymyositis and fulminant myocarditis, is described. A large amount of methylprednisolone, in addition to intra-aortic balloon pumping and percutaneous cardiopulmonary support, led to the recovery of her cardiac function. However, a massive cerebral embolism occurred and she died. Postmortem histopathological examination showed necroses of muscles and diffuse invasion of mononuclear cells in both the myocardium and the biceps muscle of her arm. Although the mechanism of cardiac dysfunction is not clear, immunosuppressive therapy was effective for fulminant myocarditis in the present case.
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Affiliation(s)
- K Yukiiri
- Second Department of Internal Medicine, Kagawa Medical University, Kita, Japan
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McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM, Baughman KL. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 2000; 342:690-5. [PMID: 10706898 DOI: 10.1056/nejm200003093421003] [Citation(s) in RCA: 556] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Lymphocytic myocarditis causes left ventricular dysfunction that may be persistent or reversible. There are no clinical criteria that predict which patients will recover ventricular function and which cases will progress to dilated cardiomyopathy. We hypothesized that patients with fulminant myocarditis may have a better long-term prognosis than those with acute (nonfulminant) myocarditis. METHODS We identified 147 patients considered to have myocarditis according to the findings on endomyocardial biopsy and the Dallas histopathological criteria. Fulminant myocarditis was diagnosed on the basis of clinical features at presentation, including the presence of severe hemodynamic compromise, rapid onset of symptoms, and fever. Patients with acute myocarditis did not have these features. The incidence of the end point of this study, death or heart transplantation, was ascertained by contact with the patient or the patient's family or by a search of the National Death Index. The average period of follow-up was 5.6 years. RESULTS A total of 15 patients met the criteria for fulminant myocarditis, and 132 met the criteria for acute myocarditis. Among the patients with fulminant myocarditis, 93 percent were alive without having received a heart transplant 11 years after biopsy (95 percent confidence interval, 59 to 99 percent), as compared with only 45 percent of those with acute myocarditis (95 percent confidence interval, 30 to 58 percent; P=0.05 by the log-rank test). Fulminant myocarditis was an independent predictor of survival after adjustments were made for age, histopathological findings, and hemodynamic variables. The rate of transplantation-free survival did not differ significantly between the patients considered to have borderline myocarditis and those considered to have active myocarditis according to the Dallas histopathological criteria. CONCLUSIONS Fulminant myocarditis is a distinct clinical entity with an excellent long-term prognosis. Aggressive hemodynamic support is warranted for patients with this condition.
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Affiliation(s)
- R E McCarthy
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Kohno K, Aoyama N, Shimohama T, Yoshida M, Machida Y, Fukuda N, Aizaki T, Suzuki K, Kurosawa T, Izumi T. Resuscitation from fulminant myocarditis associated with refractory ventricular fibrillation. JAPANESE CIRCULATION JOURNAL 2000; 64:139-43. [PMID: 10716529 DOI: 10.1253/jcj.64.139] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Resuscitation was possible in a case of fulminant myocarditis with refractory ventricular fibrillation (Vf) using a percutaneous cardiopulmonary support system (PCPS). A 46-year old Japanese man suddenly experienced cardiopulmonary dysfunction shortly after the onset of flu symptoms, was promptly diagnosed as having fulminant myocarditis and PCPS was immediately initiated. On the second day in the hospital, refractory Vf occurred, which lasted for approximately 2h despite repeated efforts to terminate it. Finally, a large dose of steroids was administered. From the third day of hospitalization and onwards, the Vf disappeared totally. The patient completely recovered from such a serious state in 6 months. During the following 3 years, he has had no clinical symptoms of worsening. As in this case demonstrates, most myocarditis is curable and invasive measures are very helpful in rescuing patients from the fulminant type with refractory Vf.
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Affiliation(s)
- K Kohno
- Department of Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan.
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20
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Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, Chu SH, Ko WJ. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999; 68:2220-4. [PMID: 10617006 DOI: 10.1016/s0003-4975(99)01174-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute myocarditis (AM) complicated with refractory cardiogenic shock carries a very high mortality. We report our experience in treating these patients, who were rescued by extracorporeal membrane oxygenation (ECMO) and intravenous immunoglobulin. METHODS Over a 5-year period, 5 patients with AM were rescued with ECMO in our hospital. Femoral venoarterial ECMO was performed in 4 patients, and right atrium-left atrium-aorta ECMO in the other 1 due to ventricular dysfunction. Hemofiltration was applied to 3 patients. Marked elevated creatine kinase, its MB form, and troponin T (TnT) were found before ECMO. RESULTS All the patients could be weaned off the ECMO after 140.0+/-57.7 hours of ECMO support. One patient died of multiple organ failure 10 days later after removal of ECMO, resulting in a 20% mortality. Renal function returned to normal in all survivors. The 4 survivors were discharged uneventfully in 23.3+/-8.3 days and resumed functional class I status. The TnT level declined to the low level within 3 days (slope -4.94+/-1.18 ng/mL/day), and might be an indicator of good recovery of myocardium. CONCLUSIONS ECMO can provide an effective and simple treatment for critical AM with a satisfactory result and reduce the possibility of progressive cardiomyopathy.
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Affiliation(s)
- Y S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei
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Ito M, Tanabe Y, Suzuki K, Kumakura M, Kimura K, Masani F, Aizawa Y. Left ventricular free wall rupture in acute fulminant myocarditis during long-term cardiopulmonary support. JAPANESE CIRCULATION JOURNAL 1999; 63:397-9. [PMID: 10943621 DOI: 10.1253/jcj.63.397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 77-year-old woman with acute myocarditis developed cardiogenic shock soon after admission and was given mechanical cardiopulmonary support. Echocardiography revealed severe global left ventricular hypokinesia. After 5 days of mechanical support, left ventricular wall motion gradually began to improve, but the patient died of cardiac tamponade on day 13. At necropsy, a free wall rupture was found where the apical akinetic area bordered the basal portion, an area which had shown better wall motion. Left ventricular free wall rupture in acute myocarditis has not been reported, but this case indicates that it may occur in fulminant myocarditis when a cardiopulmonary support system is used.
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Affiliation(s)
- M Ito
- First Department of Internal Medicine, Niigata University School of Medicine, Japan
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Kawahito K, Murata S, Yasu T, Adachi H, Ino T, Saito M, Misawa Y, Fuse K, Shimada K. Usefulness of extracorporeal membrane oxygenation for treatment of fulminant myocarditis and circulatory collapse. Am J Cardiol 1998; 82:910-1. [PMID: 9781978 DOI: 10.1016/s0002-9149(98)00503-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Prognosis for fulminant myocarditis with cardiogenic shock refractory to conventional therapy is poor. This report describes mechanical circulatory support with extracorporeal membrane oxygenation as an effective alternative for treating fulminant myocarditis with circulatory collapse.
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Affiliation(s)
- K Kawahito
- Department of Cardiovascular Surgery, Jichi Medical School, Kawachi, Tochigi, Japan
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