Endomyocardial biopsy: safety and prognostic utility in paediatric and adult myocarditis in the European Society of Cardiology EURObservational Research Programme Cardiomyopathy and Myocarditis Long-Term Registry

BACKGROUND AND AIMS

Contemporary multicentre data on clinical and diagnostic spectrum and outcome in myocarditis are limited. Study aims were to describe baseline features, 1-year follow-up, and baseline predictors of outcome in clinically suspected or biopsy-proven myocarditis (2013 European Society of Cardiology criteria) in adult and paediatric patients from the EURObservational Research Programme Cardiomyopathy and Myocarditis Long-Term Registry.

METHODS

Five hundred eighty-one (68.0% male) patients, 493 adults, median age 38 (27-52) years, and 88 children, aged 8 (3-13) years, were divided into 3 groups: Group 1 (n = 233), clinically suspected myocarditis with abnormal cardiac magnetic resonance; Group 2 (n = 222), biopsy-proven myocarditis; and Group 3 (n = 126) clinically suspected myocarditis with normal or inconclusive or no cardiac magnetic resonance. Baseline features were analysed overall, in adults vs. children, and among groups. One-year outcome events included death/heart transplantation, ventricular assist device (VAD) or implantable cardioverter defibrillator (ICD) implantation, and hospitalization for cardiac causes.

RESULTS

Endomyocardial biopsy, mainly right ventricular, had a similarly low complication rate in children and adults (4.7% vs. 4.9%, P = NS), with no procedure-related death. A classical myocarditis pattern on cardiac magnetic resonance was found in 31.3% of children and in 57.9% of adults with biopsy-proven myocarditis (P < .001). At 1-year follow-up, 11/410 patients (2.7%) died, 7 (1.7%) received a heart transplant, 3 underwent VAD (0.7%), and 16 (3.9%) underwent ICD implantation. Independent predictors at diagnosis of death or heart transplantation or hospitalization or VAD implantation or ICD implantation at 1-year follow-up were lower left ventricular ejection fraction and the need for immunosuppressants for new myocarditis diagnosis refractory to non-aetiology-driven therapy.

CONCLUSIONS

Endomyocardial biopsy was safe, and cardiac magnetic resonance using Lake Louise criteria was less sensitive, particularly in children. Virus-negative lymphocytic myocarditis was predominant both in children and adults, and use of immunosuppressive treatments was low. Lower left ventricular ejection fraction and the need for immunosuppressants at diagnosis were independent predictors of unfavourable outcome events at 1 year.

Comparative Efficacy and Safety of Mycophenolate Mofetil and Azathioprine in Combination with Corticosteroids in the Treatment of Lymphocytic Myocarditis

AIMS

This paper aimed to study the efficacy and safety of mycophenolate mofetil (MM) in combination with corticosteroids in the treatment of lymphocytic myocarditis (LM) when compared to the standard combination of corticosteroids and azathioprine.

METHODS

The study included 50 adult patients (47.8 ± 10.8 y.o.) in a NYHA III functional class due to LM who were verified using endomyocardial biopsy. The main group included 29 patients who received MM at 2 g/day. The comparison group comprised 21 patients who received azathioprine at 150 [50; 150] mg/day. Both groups were administered with methylprednisolone. The average follow-up period was 30 [22; 35] months, but no less than 6 months.

RESULTS

The groups were comparable in the baseline parameters and standard drug therapy. In both groups, there was a comparable significant increase in the ejection fraction (from 30.6 ± 7.7% to 44.0 ± 9.4% vs. 29.2 ± 7.7% to 46.2 ± 11.8%, p < 0.001), and a decrease in systolic pressure in the pulmonary artery and the dimensions of the left ventricle and atrium. The frequency of death was two (6.9%) and two (9.5%), transplantation was one (3.4%) and one (4.8%) patient and the "death + transplantation" endpoint was three (10.3%) and three (14.3%) without differences between the groups. The presence of the parvovirus B19 in the myocardium in 6/5 patients did not affect the results. The incidence of infectious complications was comparable. The most severe infectious complications were pneumonia and fatal purulent encephalitis (both cases in the azathioprine group), leptospirosis meningitis (in the mycophenolate mofetil group).

CONCLUSIONS

In the patients with LM, the combination of corticosteroids with MM at a dose of 2 g/day was at least no less effective than with azathioprine. There was a tendency toward a better tolerance using MM.

Hypertrophic Cardiomyopathy Complicated by Post-COVID-19 Myopericarditis in Patient with ANO5-Related Distal Myopathy

A 60-year-old male with hypertrophic cardiomyopathy, conduction disorders, post-COVID-19 myopericarditis and heart failure was admitted to the hospital's cardiology department. Blood tests revealed an increase in CPK activity, troponin T elevation and high titers of anticardiac antibodies. Whole exome sequencing showed the presence of the pathogenic variant NM_213599:c.2272C>T of the ANO5 gene. Results of the skeletal muscle biopsy excluded the diagnosis of systemic amyloidosis. Microscopy of the muscle fragment demonstrated sclerosis of the perimysium, moderate lymphoid infiltration, sclerosis of the microvessels, dystrophic changes and a lack of cross striations in the muscle fibers. Hypertrophy of the LV with a low contractile ability, atrial fibrillation, weakness of the distal skeletal muscles and increased plasma CPK activity and the results of the skeletal muscle biopsy suggested a diagnosis of a late form of distal myopathy (Miyoshi-like distal myopathy, MMD3). Post-COVID-19 myopericarditis, for which genetically modified myocardium could serve as a favorable background, caused heart failure decompensation.

Chronic biopsy proven post-COVID myoendocarditis with SARS-Cov-2 persistence and high level of antiheart antibodies

PURPOSE

To study the clinical signs and mechanisms (viral and autoimmune) of myoendocarditis in the long-term period after COronaVIrus Disease 2019 (COVID-19).

METHODS

Fourteen patients (nine male, 50.1 ± 10.2 y.o.) with biopsy proven post-COVID myocarditis were observed. The diagnosis of COVID-19 was confirmed by IgG seroconversion. The average time of admission after COVID-19 was 5.5 [2; 10] months. An endomyocardial biopsy (EMB) of the right ventricle was obtained. The biopsy analysis included polymerase chain reaction diagnosis of viral infection, morphological, immunohistochemical (IHC) examination with antibodies to CD3, CD45, CD68, CD20, SARS-Cov-2 spike, and nucleocapsid antigens. Coronary atherosclerosis was ruled out in all patients over 40 years.

RESULTS

The new cardiac symptoms (congestive heart failure 3-4 New York Heart Association class with severe right ventricular involvement, various rhythm, and conduction disturbances) appeared 1-5 months following COVID-19. Magnetic resonance imaging showed disseminated or focal subepicardial and intramyocardial late gadolinium enhancement, hyperemia, edema, and increased myocardial native T1 relaxation time. Antiheart antibodies levels were increased 3-4 times in 92.9% of patients. The mean left ventricular (LV) ejection fraction (EF) was 28% (24.5; 37.8). Active lymphocytic myocarditis was diagnosed in 12 patients, eosinophilic myocarditis in two patients. SARS-Cov-2 RNA was detected in 12 cases (85.7%), in association with parvovirus B19 DNA-in one. Three patients had also endocarditis (infective and nonbacterial, with parietal thrombosis). As a result of steroid and chronic heart failure therapy, the EF increased to 47% (37.5; 52.5).

CONCLUSIONS

COVID-19 can lead to long-term severe post-COVID myoendocarditis, that is characterized by prolonged persistence of coronavirus in cardiomyocytes, endothelium, and macrophages (up to 18 months) in combination with high immune activity. Corticosteroids and anticoagulants should be considered as a treatment option of post-COVID myoendocarditis.

Morphologically, immunohistochemically and PCR proven lymphocytic viral peri-, endo-, myocarditis in patients with fatal COVID-19

BACKGROUND

Despite a reported cardiac injury in patients with new coronavirus infection, the possibility and specifics of genuine viral myocarditis in COVID-19 remains not fully clear.

PURPOSE

To study the presence of SARS-CoV-2 in the myocardium and the morphological properties of myocarditis in patients with severe coronavirus infection (COVID-19).

METHODS

Autopsy data of eight elderly patients (75.6 ± 7.4 years), four male and four female, with severe new coronavirus infection were studied. The lifetime diagnosis of COVID-19 is based on a positive result of the PCR study. The inclusion criterion was the presence of morphological signs of myocarditis according to the Dallas criteria. A standard histological examination included staining by hematoxylin and eosin, toluidin blue and Van Gieson. An immunohistochemical study was performed using antibodies to CD3, CD 68, CD20, perforin, toll-like receptor (TLR) types 4 and 9. PCR in real-time was performed to determine the viral RNA in the myocardium.

RESULTS

All patients had severe bilateral viral pneumonia. In all cases, myocarditis was not clinically diagnosed. Morphological examination of the heart found signs of active lymphocytic myocarditis. PCR identified the SARS-Cov2 RNA in all cases. There were also signs of destructive coronaritis in all cases, thrombovasculitis, lymphocytic pericarditis (in 3 cases) and endocarditis (in 2 cases). The absence of neutrophils confirms the aseptic nature of inflammation. An immunohistochemical study showed the CD3-positive T lymphocytes in the infiltrates. Increased expression of TLR type 4 and less 9 was also detected.

CONCLUSION

Morphological and immunohistochemical evidence of myocarditis in COVID-19 was presented. Lymphocytic infiltrations and positive PCR confirm the viral nature of inflammation. Myocarditis in COVID-19 is also characterized by coronaritis with microvascular thrombosis and associated with lymphocytic endo- and pericarditis.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Noncompact myocardium with dilated phenotype: differences in comparison with other forms of dilated cardiomyopathy

Introduction

Noncompact myocardium (NCM) is a cardiomyopathy with various genetic causes and clinical manifestations; its relationship with other forms of dilated cardiomyopathy (DCM) and its impact on prognosis are unclear.

Objective

To study the place of NCM in the structure of DCM, its clinical features and influence on prognosis in comparison with other forms of DCM syndrome.

Methods

The NCM registry includes 125 patients, mean age 46.4±15.1 years, 74 men and 51 women, mean follow-up 14 [4.0; 41.0] months. The DCM registry included 365 patients, mean age 46.4±15.1 years, 253 men and 112 women, mean follow-up 14 [5; 43.75] months. The examination included ECG, ECG Holter monitoring, echocardiography, blood anti-heart antibody level evaluation, and additionally cardiac CT, MRI, DNA diagnostics (in the MYH7, MYBPC3, TPM1, TNNI3, TNNT2, ACTC1, TAZ, ZASP (LDB3), MYL2, MYL3, DES, LMNA, EMD, TTR gene panel), coronary angiography, right ventricular endomyocardial biopsy.

Results

The proportion of patients with DCM phenotype in the NCM registry was 40% (n=49), another 11% (n=15) had DCM syndrome diagnosed simultaneously with acute/subacute myocarditis. Lethality in these subgroups was 12.2% and 33.3%, respectively, and was significantly higher than in asymptomatic, ischemic and arrhythmic variants of DCM. In the DCM registry, the proportion of patients with NCM was 21% (n=78), and increased left ventricular (LV) trabecularity was detected in another 18% (n=64). DCM patients with and without NCM did not differ by baseline echocardiographic parameters, heart failure class, and cardiotropic therapy. Pathogenic mutations were detected in 14% of DCM patients with NCM and only 3% of other patients with DCM (p&lt;0.001). Only in patients without NCM the presence of mutations had a significant effect on lethality. The patients with NCM compared with the others DCM patients showed significantly lower increase in EF in early and late period (from 31.0±10.2 to 34.8±11.0 and 37.1±10.9% vs from 31.8±9.7 to 38.8±11.3 and 42.3±12.4%, p&lt;0.05 vs 05 and &lt;0.01, respectively), a greater incidence of PVBs (1568 [105; 7000] vs 543.5 [77.75; 3194], p&lt;0.05), appropriate defibrillator shocks and sudden deaths (17.9 vs 5.9%, p&lt;0.001), intracardiac thrombosis (21.8 vs 13.5%, p=0.069) despite a greater frequency of anticoagulants (73.1 vs 57.4%, p&lt;0&lt;05). There were no significant differences in death (19.2 vs 18.5%) and transplantation (7.7 vs 3.8%) between patients with and without NCM. There were no cases of NCM regression.

Conclusion

NCM is an independent form of DCM syndrome, which is characterized by higher frequency of pathogenic mutations, arrhythmic events, worse response to cardiotropic therapy, higher frequency of intracardiac thrombosis. The absence of mortality differences can be explained by the higher frequency of preventive interventions in this category of patients with DCM (prescription of anticoagulants, defibrillator implantation, heart transplantation).

Funding Acknowledgement

Type of funding sources: None.

The correlation of anti-heart antibodies levels with clinical manifestations and outcomes in patients with COVID-19

Purpose

To evaluate the blood level of anti-heart antibodies (AHA) and its correlation with clinical outcomes in patients with severe and moderate COVID-19.

Methods

The study included 34 patients (11 females and 23 males, mean age 58.3±17.6 years, from 20 to 87 years) who underwent treatment for moderate and severe COVID-19 at the Sechenov University hospital in April-June 2020. The diagnosis was confirmed by 50% using nasopharyngeal smears. In other cases, the diagnosis of COVID-19 was based on the following criteria: contact with a serologically confirmed COVID-19 patient, persistent fever of at least 38 degrees Celsius, typical CT findings of viral pneumonia, typical changes in blood tests in the absence of evidence for other diseases. Besides standard medical examination the AHA blood levels by immunoassay were observed, including antinuclear antibodies (ANA), antiendothelial cell antibodies (AECA), anti-cardiomyocyte antibodies (AbC), anti-smooth muscle antibodies (ASMA) and cardiac conducting tissue antibodies (CCTA). Median hospital length of stay was 14 [13; 18] days.

Results

AHA levels were increased in 25 (73.5%) patients. The patients were divided into the five groups: 1.Patients with previous chronic myocarditis who had already been receiving immunosuppressive therapy at the admission (n=4). Moderate titer increase was noted only in one patient. 2.Patients with severe COVID-19 and high inflammatory activity, in whom the degree of AHA increase matched the general disease activity. 3. Patients with severe COVID-19 and high inflammatory activity without AHA increase. 4. Patients with moderate COVID-19, in whom high AHA titers may reflect chronic latent myocarditis not associated with SARS-Cov2. 5. Patients with moderate COVID-19 and nearly normal / normal AHA titers. Significant correlation (p<0.05) of AHA levels with cardiovascular manifestations (r=0.459) was found. AbC levels correlated significantly with pneumonia severity (r=0.472), respiratory failure (r=0.387), need for invasive ventilation (r=0.469), chest pain (r=0.374), low QRS voltage (r=0.415) and high levels of CRP (r=0.360) and LDH (r=0.360). ASMA levels were found to correlate significantly with atrial fibrillation (r=0.414, p<0.05). ANA and AbC levels correlated significantly with pericardial effusion (r=0.721 and r=0.745 respectively, p<0.05). The lethality rate was 8.8%. AbC and ASMA levels correlated significantly with lethality (r=0.363, and r=0.426 respectively, p<0.05) and were prognostically important.

Conclusion

Elevated titres of AHA were found in 73.5% of patients. AHA correlated with lethality, in most cases reflecting the overall activity and severity of the disease and may be considered within the systemic immune and inflammatory response in COVID-19. At the same time, the correlation with signs of myocardial injury and pericardial effusion, confirms the direct role of AHA in the inflammatory heart disease (myopericarditis).

FUNDunding Acknowledgement

Type of funding sources: None.

Post-COVID myocarditis diagnosed by endomyocardial biopsy and/or magnetic resonance imaging 2–9 months after acute COVID-19

Purpose

To study clinical features of myocarditis and its possible mechanisms (including persistence of SARS-Cov-2 in the myocardium) in the long-term period after acute COVID-19.

Methods

Fifteen patients (8 male and 7 female, mean age 47.8±13.4, 24–65 years) diagnosed with postcovid myocarditis were included in the study. The diagnosis of COVID-19 was confirmed by positive PCR results in 40%, and seroconversion in all patients. The average time of admission after COVID-19 was 4 [3; 7] months, from 2 to 9 months. The diagnosis of myocarditis was confirmed by cardiac MRI in 10 patients and by right ventricular endomyocardial biopsy (EMB) in 6 patients. The PCR for cardiotropic viruses and PCR with immunohistochemical study for SARS-Cov2 detection were used. All patients had study for anti-heart antibodies (AHA), EchoCG, and Holter ECG. Coronary atherosclerosis was excluded in all patients over 40 years (7 coronary angiography, 4 cardiac CT).

Results

A clear association of the cardiac symptoms with a previous new coronavirus infection was noted in all patients. The symptoms started 1–5 months following COVID-19. MRI showed subepicardial and intramyocardial LGE, signs of hyperemia, increased T1 relaxation time, edema. AHA levels were increased 3–4-fold in 73%. Two variants of postcovid myocarditis were observed. 1. Arrhythmic variant (n=6) – newly developed frequent supraventricular or ventricular extrasystole, recurrent atrial fibrillation in the absence of systolic dysfunction. 2. Decompensated variant with biventricular heart failure (n=9): the mean LV EF was 34.1±7.8% (23 to 46%), LV EDD 5.8±0.7 cm, EDV 153.8±46.1 ml, pulmonary artery systolic pressure 40.7±11.2 mmHg. In one case, myocarditis was accompanied by IgG4- and ANCA-negative aortitis. SARS-Cov-2 RNA was detected in 4 of 5 myocardial biopsies (in one case the material in the study). The longest period of virus persistence after COVID-19 was 9 months. By using spike and nucleocapsid antibodies, coronavirus was detected in cardiomycytes and macrophages. Data of patients with morphologically proved myocarditis are presented in Table 1. Lymphocytic myocarditis was diagnosed and confirmed immunohistochemically (n=5); giant cell myocarditis with atrial standstill was detected in one more case (Fig. 1). Three patients had also signs of endocarditis, in two cases with parietal thrombosis.

Conclusions

COVID-19 can lead to the subacute and chronic myocarditis of varying severity. Post-COVID myocarditis manifests itself in two main clinical forms - isolated arrhythmias and systolic dysfunction with heart failure. Post-COVID myocarditis is characterized by prolonged persistence of coronavirus (up to 9 months in this study, in most patients with decompensated variant) in combination with high immune activity (high titers of AHA), which should be considered as the main mechanisms of its long-term course. Treatment approaches for such myocarditis require investigation.

Funding Acknowledgement

Type of funding sources: None. Table 1. Patients with EMB proved myocarditisFigure 1. The EMB in postcovide myocarditis

Post-COVID morphologically proved endocarditis: infective and nonbacterial forms

Purpose

To study clinical features of endocarditis and its possible mechanisms (infective and nonbacterial) in the long-term period after acute COVID-19.

Methods

Three patients (two male and one female, age 64, 39 and 46 years) diagnosed with postcovid endocarditis were included in the study. One patient had severe bilateral coronavirus pneumonia; the other two had only fever and weakness. The diagnosis of COVID-19 was confirmed by seroconversion. The time of admission after COVID-19 was from 4 to 7 months. All patients had study for anti-heart antibodies (AHA), EchoCG, Holter ECG, and endomyocardial biopsy (EMB) with PCR for SARS-Cov2 and cardiotropic viruses. The indication for EMB was suspected myocarditis. Blood cultures and procalcitonin levels were tested in one patient due to a prolonged febrile fever.

Results

Two variants of postcovid endocarditis have been diagnosed. The first variant was detected in two patients by EMB only. This patients had severe lymphocytic and giant cell myocarditis. In addition, EMB showed signs of lymphocytic endocarditis with infiltrates, marked thickening and fibrosis of the endocardium (Fig. 1). Some biopsy specimen were represented by fresh thrombotic masses, infiltrated with neutrophilic leukocytes. No intraventricular thrombus was detected on EchoCG and MRI. The second variant of postcovid endocarditis developed in a patient with bicuspid aortic valve and met the criteria of infectious endocarditis 2015: mobile vegetations on the valve with aortic regurgitation II, splenomegaly, irregular fever up to 39°C for six months, marked increase of CRP, procalcitonin and ferritin, hypochromic anemia, LV EF 25%. Blood culture was negative. After intravenous therapy with antibiotics and immunoglobulin, EMB confirmed the active lymphocytic myocarditis and only slight fibrosis of right ventricular endocardium. The bacteriological study of endocardium was negative. SARS-Cov-2 RNA was detected by PCR in myocardial biopsy specimens of two patients; the biopsy of one patient is in the study now. All patients had significantly elevated antibody titers to various cardiac antigens, but the level of antibodies to endothelial antigens remained completely normal. It is possible to suggest an active deposition of immune complexes in the endothelium. Two surviving patients receive steroid therapy (in case of IE with antibiotics).

Conclusions

SARS-Cov-2 infection induces the prolonged non-bacterial thromboendocarditis or infective endocarditis. In both cases, autoimmune mechanisms play a significant role, as evidenced by the simultaneous lymphocytic/giant cell myocarditis and high titers of AHA. Long-term persistence of coronavirus in the myocardium can also be considered as an etiological factor of endocarditis. In favor of this hypothesis is the parietal thrombosis in the absence of bacterial infection. Corticosteroids and anticoagulants should be considered for the treatment of postcovid endocarditis.

Funding Acknowledgement

Type of funding sources: None.

Progressive chronic SARS-CoV-2-positive giant cell myoendocarditis with atrial standstill and sudden cardiac death

Giant cell myocarditis (GCM) is a rare condition. Its association with SARS‐CoV‐2 has not been described before. The 46‐year‐old female patient was admitted to the clinic on September 2020. She had 7 year adrenal insufficiency history and infarct‐like debut of myocardial disease in November 2019. After COVID‐19 in April 2020, cardiac disease progressed. The examination showed low QRS voltage, QS complexes in V₁–V₅ leads, atrial standstill, left ventricular systolic and restrictive dysfunction, elevated anti‐heart antibodies, and subepicardial late gadolinium enhancement by magnetic resonance imaging. Endomyocardial biopsy and pacemaker implantation were performed, but the patient died suddenly due to ventricular tachycardia or ventricular fibrillation (the resuscitation was ineffective). The autopsy revealed GCM, SARS‐CoV‐2, and Parvovirus B19 were detected in the myocardium. The role of SARS‐CoV‐2 in the pathogenesis of autoimmune myocarditis is discussed.

Anti-heart antibodies levels and their correlation with clinical symptoms and outcomes in patients with confirmed or suspected diagnosis COVID-19

The aim of this study is to evaluate the blood level of anti-heart antibodies (AHA) and its correlation with clinical outcomes in patients with severe and moderate coronavirus disease 2019 (COVID-19). The study included 34 patients (23 males; mean age 60.2 ± 16.6 years) with COVID-19 pneumonia. Besides standard medical examination, the AHA blood levels were observed, including antinuclear antibodies, antiendothelial cell antibodies, anti-cardiomyocyte antibodies (AbC), anti-smooth muscle antibodies (ASMA), and cardiac conducting tissue antibodies. Median hospital length of stay was 14 [13; 18] days. AHA levels were increased in 25 (73.5%) patients. Significant correlation (p < 0.05) of AHA levels with cardiovascular manifestations (r = 0.459) was found. AbC levels correlated with pneumonia severity (r = 0.472), respiratory failure (r = 0.387), need for invasive ventilation (r = 0.469), chest pain (r = 0.374), low QRS voltage (r = 0.415), and levels of C-reactive protein (r = 0.360) and lactate dehydrogenase (r = 0.360). ASMA levels were found to correlate with atrial fibrillation (r = 0.414, p < 0.05). Antinuclear antibodies and AbC levels correlated with pericardial effusion (r = 0.721 and r = 0.745, respectively, p < 0.05). The lethality rate was 8.8%. AbC and ASMA levels correlated significantly with lethality (r = 0.363 and r = 0.426, respectively, p < 0.05) and were prognostically important. AHA can be considered as part of the systemic immune and inflammatory response in COVID-19. Its possible role in the inflammatory heart disease requires further investigation.

Plasma exchange in patients with myocarditis: comparison study

Background

Cardiac auto-antibodies (AABs) are detected frequently in patients with inflammatory dilated cardiomyopathy (iDCM) of arrhythmias due to myocarditis. Elimination of AABs with apheresis improves left ventricular function as well as the immunosuppressive drugs (ISDs) do. There is no data on the combined use of ISDs and apheresis.

Aims

To investigate the clinical efficiency of plasma exchange (PE) in patients with myocarditis in comparison with patients without PE.

Methods

There were 38 patients with iDCM under stable oral medication with maximal tolerated dose of β-blockers/angiotensin-converting enzyme inhibitor/aldosterone antagonists at least 3 month before study inclusion; and 48 patients with arrhythmias due to myocarditis resistant to antiarrhythmic drugs (AADs). Patients underwent evaluation including heart CT scan, MRI, endomyocardial biopsy, myocardial perfusion scan, and coronary angiography to diagnose myocarditis. All the patients had a high level of AABs against cardiac antigens. PE group were consisted of 19 patients with iDCM (left ventricular ejection fraction (LVEF) 35±7%) and 22 patients with arrhythmias (premature atrial (PACs) or ventricular (PVCs) contractions more than 3000/day or atrial fibrillation (AF)). All the patients in PE group underwent a single volume PE filled with 0.9% sodium chloride. Another 19 iDCM patients and 26 arrhythmic patients were controls without PE. Echocardiographic parameters, a 6-minute walk test (6MWT) distance, Holter monitoring and AABs level were assessed at baseline, 6 and 12 month follow-up. Some patients were treated by ISDs before PE. PE group patients got methylprednisolone (MP) significantly rare than controls after PE. The mean doses of MP were significantly lower than in controls too.

Results

AABs level significantly decreased just after PE and during the follow-up only in PE group. iDCM patients also had significant improvement in LVEF 35±7% vs. 45±11% at a year follow up, and 6MWT distance in comparison with LVEF 33±7% vs. 37±11% at a year follow up in controls. There were 58% PE group patients with absolute LVEF improvement &gt;10% classified as responders in comparison with 32% responders in controls. There were 86% PE group patients with arrhythmias in and 58% patients in control group who were classified as responders as they achieved a decrease of PAVs and PVCs or AF frequency &gt;75% relative to baseline. AADs were eliminated in 46% PE group patients and in 23% control group patients with arrhythmias. We also tried to predict good response for PE in both iDCM and arrhythmic patients. iDCM responders were characterized by LVEF≤37% at baseline. Arrhythmic group responders were characterized by higher level of AABs to cardiac conduction cells antigens at baseline.

Conclusions

PE improves both cardiac function and daily activities in patients with iDCM and arrhythmias due to myocarditis. PE is safe and high effective, and helps avoid using high doses of ISDs

Funding Acknowledgement

Type of funding source: None

Mixed Hypertrophic and Dilated Phenotype of Cardiomyopathy in a Patient With Homozygous In-Frame Deletion in the MyBPC3 Gene Treated as Myocarditis for a Long Time

Hypertrophic cardiomyopathy (HCM) is the most common inherited disease, with a prevalence of 1:200 worldwide. The cause of HCM usually presents with an autosomal dominant mutation in the genes encoding one of more than 20 sarcomeric proteins, incomplete penetrance, and variable expressivity. HCM classically manifests as an unexplained thickness of the interventricular septum (IVS) and left ventricular (LV) walls, with or without the obstruction of the LV outflow tract (LVOT), and variable cardiac arrhythmias. Here, we present a rare case of mixed cardiomyopathy (cardiac hypertrophy and dilation) and erythrocytosis in a young patient. A 27-year-old man was admitted to the clinic due to biventricular heart failure (HF) NYHA class III. Personal medical records included a diagnosis of dilated cardiomyopathy (DCM) since the age of 4 years and were, at the time, considered an outcome of myocarditis. Severe respiratory infection led to circulatory decompensation and acute femoral thrombosis. The combination of non-obstructive LV hypertrophy (LV walls up to 15 mm), LV dilatation, decreased contractility (LV EF 24%), and LV apical thrombosis were seen. Cardiac MRI showed a complex pattern of late gadolinium enhancement (LGE). Endomyocardial biopsy (EMB) revealed primary cardiomyopathy with intravascular coagulation and an inflammatory response. No viral genome was detected in the plasma or EMB samples. Whole exome sequencing (WES) revealed a homozygous in-frame deletion p.2711_2737del in the MyBPC3 gene. The clinically unaffected mother was a heterozygous carrier of this deletion, and the father was unavailable for clinical and genetic testing. Essential erythrocytosis remains unexplained. No significant improvement was achieved by conventional treatment, including prednisolone 40 mg therapy. ICD was implanted due to sustained VT and high risk of SCD. Orthotopic heart transplantation (HTx) was considered optimal. Early manifestation combined hypertrophic and dilated phenotype, and progression may reflect a complex genotype with more than one pathogenic allele and/or a combination of genetic diseases in one patient.

Atrial fibrillation, anticoagulation management and risk of stroke in the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Aims

Cardiomyopathies are a heterogeneous group of disorders that increase the risk for atrial fibrillation (AF). The aim of the study is to assess the prevalence of AF, anticoagulation management, and risk of stroke/transient ischaemic attack (TIA) in patients with cardiomyopathy.

Methods and results

Three thousand two hundred eight consecutive adult patients with cardiomyopathy (34.9% female; median age: 55.0 years) were prospectively enrolled as part of the EURObservational Research Programme Cardiomyopathy/Myocarditis Registry. At baseline, 903 (28.2%) patients had AF (29.4% dilated, 27.5% hypertrophic, 51.5% restrictive, and 14.7% arrhythmogenic right ventricular cardiomyopathy, P < 0.001). AF was associated with more advanced New York Heart Association class (P < 0.001), increased prevalence of cardiovascular risk factors and co‐morbidities, and a history of stroke/TIA (P < 0.001). Oral anticoagulation was administered in 71.7% of patients with AF (vitamin K antagonist: 51.6%; direct oral anticoagulant: 20.1%). At 1 year follow‐up, the incidence of cardiovascular endpoints was as follows: stroke/TIA 1.85% (AF vs. non‐AF: 3.17% vs. 1.19%, P < 0.001), death from any cause 3.43% (AF vs. non‐AF: 5.39% vs. 2.50%, P < 0.001), and death from heart failure 1.67% (AF vs. non‐AF: 2.44% vs. 1.31%, P = 0.033). The independent predictors for stroke/TIA were as follows: AF [odds ratio (OR) 2.812, P = 0.005], history of stroke (OR 7.311, P = 0.010), and anaemia (OR 3.119, P = 0.006).

Conclusions

The study reveals a high prevalence and diverse distribution of AF in patients with cardiomyopathies, inadequate anticoagulation regimen, and high risk of stroke/TIA in this population.

Immunosuppressive therapy of biopsy proved immune-mediated lymphocytic myocarditis in the virus-negative and virus-positive patients

PURPOSE

to study the effect of immunosupressive therapy (IST) in the virus-negative and virus-positive patients with immune-mediated myocarditis.

METHODS

in 60 patients (45 male, 46.7 ± 11.8 years, mean LV EDD, 6.7 ± 0.7 cm, EF 26.2 ± 9.1%) active/borderline myocarditis was verified by endomyocardial biopsy (n = 38), intraoperative biopsy (n = 10), examination of explanted heart (n = 3) and autopsy (n = 9). Indications for IST determined based on histological, immune activity. The follow-up was 19.0 [7.25; 40.25] months.

RESULTS

The viral genome in the myocardium was detected in 32 patients (V+ group), incl. parvovirus B19 in 23. The anti-heart antibody level was equally high in the V+ and V- patients. Antiviral therapy was administered in 24 patients. IST (in 22 V+ and 24 V- patients) include steroids (n = 40), hydroxychloroquine (n = 20), azathioprine (n = 21). The significant decrease of LV EDD (6.7 ± 0.7 to 6.4 ± 0.8), PAP (48.9 ± 15.5 to 39.4 ± 11.5 mm Hg, р<0,01), increase of EF (26.5 ± 0.9 to 36.0 ± 10.8), and lower lethality (23.9% and 64.3%; RR 0.37, 95% CI 0.19-0.71), p<0.01, were found only in IST group. Significant improvement due to IST were achieved not only in V-, but also in V+ patients.

CONCLUSIONS

IST in patients with immune-mediated lymphocytic myocarditis is effective and is associated with lower lethality both in virus-negative and virus-positive patients.

Clinical Classification of Arrhythmogenic Right Ventricular Cardiomyopathy

Introduction

Commonly accepted clinical classification of arrhythmogenic right ventricular cardiomyopathy (ARVC) is still not developed.

Objective

To study the clinical forms of ARVC.

Methods

Fifty-four patients (38.7 ± 14.1 years, 42.6% men) with ARVC. Follow-up period: 21 (6-60) months. All patients underwent electrocardiography, 24 h-Holter monitoring, echocardiography, and DNA diagnostic. Magnetic resonance imaging was performed in 49 patients.

Results

According to the features of clinical course of ARVC, 4 clinical forms were identified. (I) Latent arrhythmic form (n = 27) - frequent premature ventricular contractions and/or nonsustained ventricular tachycardia (VT) in the absence of sustained VT and syncope; characterized by absence of fatal arrhythmic events. (II) Manifested arrhythmic form (n = 11) - sustained VT/ventricular fibrillation; the high incidence of appropriate implantation of cardioverter-defibrillator (ICD) interventions (75%) registered. (III) ARVC with progressive chronic heart failure (CHF, n = 8) as the main manifestation of the disease; incidence of appropriate ICD interventions was 50%, mortality rate due to CHF was 25%. (IV) Combination of ARVC with left ventricular noncompaction (n = 8); characterized by mutations in desmosomal or sarcomere genes, aggressive ventricular arrhythmias, appropriate ICD interventions in 100% patients. Described 4 clinical forms are stable in time, do not transform into each other, and they are genetically determined.

Conclusions

The described clinical forms of ARVC are determined by a combination of genetic and environmental factors and do not transform into each other. The proposed classification could be used in clinical practice to determine the range of diagnostic and therapeutic measures and to assess the prognosis of the disease in a particular patient.

P4682Left ventricular noncompaction in adults: complications, their predictors and outcomes

Background

Left ventricular noncompaction (LVNC) is characterized by high frequency of heart failure, arrhythmias, thromboembolism and ischemia.

Purpose

To estimate frequency, predictors, outcomes of adverse events in patients with LVNC.

Methods

120 patients with LVNC were included (male, 58.3%); mean age, 45.9±15.0 years. To diagnose LVNC EchoCG (n=120), CT (n=85), MRI (n=55) were performed. The mean LV EF was 39.0±13.9%, LV EDV 155.5±65.0ml, LV EDD 6,03±0.8cm, LA volume 96.3±38.4ml. The median follow-up was 15 [4.0; 41.0] months. We also performed NGS sequencing, followed by Sanger sequencing.

Results

Pathological mutations in genes MYH7, MyBPC3, LAMP2, DES, DSP, TTN were found in 10% of patients. The main clinical manifestations were chronic heart failure NYHA II-III (66.7% of patients), ventricular arrhythmias (PVCs>500/day in 46.7%, sustained/unsustained VT in 49.2%), AF 30.8% (paroxysmal, n=18; persistent, n=11; permanent, n=9), ischemia (angina pectoris in 20%, myocardial necrosis in 13.3%), intracardiac thrombosis without anticoagulants (19.2%), embolism (6.7%), AV block degree II-III (11.7%), bundle branch blocks (37.5%), sinus node dysfunction (10%). VT frequency was associated with lower LV EF (34.6±13.4 v 42.8±13.1 p=0.001), higher NYHA functional class (class 2.5 [2.0; 3.0] v class 2 [0.75; 3.0], p<0,01), low voltage ECG (20.3% v 5.2% p<0,05), poor R-wave progression (42.4% v 20.7% p<0,01), QRS duration (110ms [100; 140] v 100ms [90; 110], p=0,001), myocarditis presence (66.1% v 37.9% p<0.01) and higher mortality (22% v 6.9% p<0.05). AF correlated with the size of LA (AUC 0.712), and RA (AUC 0.716), p<0.001. Pacemakers were implanted in 7 cases, ICD in n=25 (20.8%), CRTD in n=9 (7.5%). Appropriate ICD shocks were recorded in 26.5%. In two patients without ICD sudden cardiac death occurred. Radiofrequency ablation was performed in 5 cases, in 3 of them without effect. Patients with thromboembolic events (renal, pulmonary, myocardial infarction, stroke) had significantly lower LV EF (31.8%±11.4 v 41.0±13.9%, p<0.005), higher NYHA functional class (class 3 [1.75; 3.0] v class 2 [1.0; 3.0], p<0.05), greater LV EDD (6.34±0.83 v 5.9±0.81, p<0.05), E/A ratio (2.15±0.8 v 1.5±0.84 p<0.01), lower VTI (10.19±2.9 v 12.8±3.6 p<0.05). The main MI mechanisms were embolism, thrombosis, myocarditis, inadequate myocardium perfusion. Six patients (5%) underwent heart transplantation. The mortality rate was 14.2% (17 patients) due to myocardial infarction, arrhythmias, heart failure.

Conclusion

Thromboembolic events, arrhythmias and ischemia are typical adverse events of LVNC. Non-sustained/sustained ventricular tachycardia, myocardial infarction is significantly associated with increased mortality. LV dilation, systolic and diastolic dysfunction increases the frequency of thromboembolism in these patients. Low voltage ECG, poor R-wave progression, QRS duration and myocarditis should considered predictors for arrhythmias in LVNC patients.

Diagnostic Value of Different Noninvasive Criteria of Latent Myocarditis in Comparison with Myocardial Biopsy

Purpose: The aim of this study was to quantify the value of various clinical, laboratory, and instrumental signs in the diagnosis of myocarditis in comparison with morphological studies of the myocardium. Methods: In 100 patients (65 men, 44.7 ± 12.5 years old) with “idiopathic” arrhythmias (n = 20) and dilated cardiomyopathy (DCM; n = 80), we performed the following: 71 endomyocardial biopsies (EMB), 13 intraoperative biopsies, 5 studies of explanted hearts, and 11 autopsies with virus investigation (real-time PCR) of the blood and myocardium. Antiheart antibodies (AHA) were also measured as well as cardiac CT (n = 45), MRI (n = 25), and coronary angiography (n = 47). The comparison group included 50 patients (25 men, 53.7 ± 11.7 years old) with noninflammatory heart diseases who underwent open heart surgery. Results: Active/borderline myocarditis was diagnosed in 76.0% of the study group and in 21.6% of patients in the comparison group (p < 0.001). The myocardial viral genome was observed more frequently in patients in the comparison group than in the study group (65.0 and 40.2%; p < 0.01). We evaluated the diagnostic value of noninvasive markers of myocarditis. The panel of AHA had the greatest importance in the identification of myocarditis: sensitivity was 81.5%, and the positive and negative predictive values were 75.0 and 60.5%. This defined the diagnostic value of noninvasive markers of myocarditis and established a diagnostic algorithm providing an individual assessment of the likelihood of myocarditis development. Conclusion: AHA have the greatest significance in the diagnosis of latent myocarditis in patients with “idiopathic” arrhythmias and DCM. The use of a complex of noninvasive criteria allows the probability of myocarditis to be estimated and the indications for EMB to be determined.

Dilated cardiomyopathy with severe arrhythmias in Emery-Dreifuss muscular dystrophy: from ablation to heart transplantation

We present 38-years male patient. He has suffered from muscle weakness since 5 years. Arrhythmias appeared at the age of 32. In 37 years he had sick sinus syndrome, transient AV block II degree, paroxysmal atrial fibrillation, atrial flutter, ventricular arrhythmias. At this time, dilated cardiomyopathy was also detected. The evaluation revealed knees and elbows contractures, increased level of creatine kinase. The genetic testing revealed a frame shift deletion c.del619C in the emerin (EMD) gene and c.IVS4-13T> A in the lamin (LMNA) gene, and c.del619C deletion in the heterozygous state in a patient`s mother. Radiofrequency ablation of cavotricuspid isthmus, implantable cardioverter-defibrillator (ICD) implantation were performed. Heart transplantation was performed nine months later, due to severe heart failure and electrical storm. A morphological evaluation revealed sclerosis, atrophy and hypertrophy of cardiomyocytes. He underwent an induction therapy with (basiliximab) methylprednisolone, tacrolimus, mycophenolate after heart transplantation. During 40 months after transplantation, patient`s condition is satisfactory.

CONCLUSION

heart failure in Emery-Dreifuss muscular dystrophy can progress quickly unless the previously stable condition. The use of correct regimens of immunosuppression therapy provides good long-term results of the heart transplantation.