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Ammirati E, Cipriani M, Lilliu M, Sormani P, Varrenti M, Raineri C, Petrella D, Garascia A, Pedrotti P, Roghi A, Bonacina E, Moreo A, Bottiroli M, Gagliardone MP, Mondino M, Ghio S, Totaro R, Turazza FM, Russo CF, Oliva F, Camici PG, Frigerio M. Survival and Left Ventricular Function Changes in Fulminant Versus Nonfulminant Acute Myocarditis. Circulation 2017; 136:529-545. [PMID: 28576783 DOI: 10.1161/circulationaha.117.026386] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/24/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Previous reports have suggested that despite their dramatic presentation, patients with fulminant myocarditis (FM) might have better outcome than those with acute nonfulminant myocarditis (NFM). In this retrospective study, we report outcome and changes in left ventricular ejection fraction (LVEF) in a large cohort of patients with FM compared with patients with NFM. METHODS The study population consists of 187 consecutive patients admitted between May 2001 and November 2016 with a diagnosis of acute myocarditis (onset of symptoms <1 month) of whom 55 required inotropes and/or mechanical circulatory support (FM) and the remaining 132 were hemodynamically stable (NFM). We also performed a subanalysis in 130 adult patients with acute viral myocarditis and viral prodrome within 2 weeks from the onset, which includes 34 with FM and 96 with NFM. Patients with giant-cell myocarditis, eosinophilic myocarditis, or cardiac sarcoidosis and those <15 years of age were excluded from the subanalysis. RESULTS In the whole population (n=187), the rate of in-hospital death or heart transplantation was 25.5% versus 0% in FM versus NFM, respectively (P<0.0001). Long-term heart transplantation-free survival at 9 years was lower in FM than NFM (64.5% versus 100%, log-rank P<0.0001). Despite greater improvement in LVEF during hospitalization in FM versus NFM forms (median, 32% [interquartile range, 20%-40%] versus 3% [0%-10%], respectively; P<0.0001), the proportion of patients with LVEF <55% at last follow-up was higher in FM versus NFM (29% versus 9%; relative risk, 3.32; 95% confidence interval, 1.45-7.64, P=0.003). Similar results for survival and changes in LVEF in FM versus NFM were observed in the subgroup (n=130) with viral myocarditis. None of the patients with NFM and LVEF ≥55% at discharge had a significant decrease in LVEF at follow-up. CONCLUSIONS Patients with FM have an increased mortality and need for heart transplantation compared with those with NFM. From a functional viewpoint, patients with FM have a more severely impaired LVEF at admission that, despite steep improvement during hospitalization, remains lower than that in patients with NFM at long-term follow-up. These findings also hold true when only the viral forms are considered and are different from previous studies showing better prognosis in FM.
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Affiliation(s)
- Enrico Ammirati
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.).
| | - Manlio Cipriani
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Marzia Lilliu
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Paola Sormani
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Marisa Varrenti
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Claudia Raineri
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Duccio Petrella
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Andrea Garascia
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Patrizia Pedrotti
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Alberto Roghi
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Edgardo Bonacina
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Antonella Moreo
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Maurizio Bottiroli
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Maria P Gagliardone
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Michele Mondino
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Stefano Ghio
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Rossana Totaro
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Fabio M Turazza
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Claudio F Russo
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Fabrizio Oliva
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Paolo G Camici
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Maria Frigerio
- From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
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