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Rav-Acha M, Shah K, Hasin T, Gumuser E, Tovia-Brodie O, Shauer A, Konstantino Y, Yair E, Wolak A, Sinai E, Ziv-Baran T, Amsalem I, Michowitz Y, Glikson M, Heist K, Ng CY. Incidence and Predictors for Recurrence of Ventricular Arrhythmia Presenting During Acute Myocarditis: A Multicenter Study. JACC Clin Electrophysiol 2024:S2405-500X(24)00173-7. [PMID: 38661603 DOI: 10.1016/j.jacep.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Management of acute myocarditis (AM) patients experiencing ventricular arrhythmia (VA) during acute illness is controversial, especially regarding early implantable cardioverter-defibrillator (ICD) implantation. OBJECTIVES The purpose of this study was to evaluate the prevalence of and find predictors for long-term sustained VA recurrence and overall mortality among AM patients with VA. METHODS This was a multicenter retrospective analysis of AM patients (verified by cardiac magnetic resonance imaging or myocardial biopsy) with documented VA during the acute illness ("initial VA"). Patients with history of myocardial infarction, heart failure, or VA were excluded. The study endpoint was a composite of sustained VA and overall mortality during follow-up. RESULTS The study included 69 AM patients with initial VA: sustained monomorphic ventricular tachycardia (MMVT) (n = 25), sustained polymorphic ventricular tachycardia (VT)/ventricular fibrillation (n = 13), and nonsustained VT (n = 31). Age was 44 ± 13 years, and 23 of 69 (33.3%) were women. During median follow-up of 5.5 years, 27 of 69 (39%) patients reached the composite endpoint including sustained VA (n = 24) and death (n = 11). Initial MMVT, predischarge left ventricular dysfunction (left ventricular ejection fraction <50%), and anteroseptal delayed enhancement on cardiac magnetic resonance imaging were significantly associated with the composite endpoint. On multivariable analysis, initial MMVT (HR: 5.17; 95% CI: 1.81-14.6; P = 0.001) and predischarge LV dysfunction (HR: 4.57; 95% CI: 1.83-11.5; P = 0.005) were independently associated with the composite endpoint. Using these 2 predictors, we could delineate subgroups with low (∼4%), medium (∼42%), and high (∼82%) 10-year incidence of composite endpoint. CONCLUSIONS AM patients presenting with VA have high incidence of sustained VA recurrence and mortality posthospitalization. Initial MMVT and predischarge LV dysfunction are independently associated with VA recurrence and mortality. Implantable cardioverter-defibrillator implantation may be considered in such high-risk patients.
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Affiliation(s)
- Moshe Rav-Acha
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel.
| | - Kushal Shah
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Tal Hasin
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Ezra Gumuser
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Oholi Tovia-Brodie
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Ayelet Shauer
- Cardiology Dept. Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Yuval Konstantino
- Cardiology Department, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Eyal Yair
- Bar-Ilan University, Tek-Aviv, Israel
| | - Arik Wolak
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Eden Sinai
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Tomer Ziv-Baran
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itzak Amsalem
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Yoav Michowitz
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Michael Glikson
- Integrated Heart Center, Shaare Zedek Hospital, Hebrew University, Jerusalem, Israel
| | - Kevin Heist
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chee Yuan Ng
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
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Rasal G, Deshpande M, Mumtaz Z, Phadke M, Mahajan A, Nathani P, Lokhandwala Y. Arrhythmia spectrum and outcome in children with myocarditis. Ann Pediatr Cardiol 2021; 14:366-371. [PMID: 34667410 PMCID: PMC8457292 DOI: 10.4103/apc.apc_207_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 05/01/2021] [Accepted: 05/10/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction Myocarditis remains an under-diagnosed entity among children. We evaluated the spectrum of electrocardiogram (ECG) changes and arrhythmias in children with myocarditis. Methods A single-center prospective observational study was conducted over a period of 18 months at a public university hospital, which included all cases with myocarditis from the ages of 1 month to 12 years. Myocarditis was diagnosed according to standard criteria. Arrhythmias were detected by 12-lead ECG or by multiparameter monitors. Results There were 63 children with myocarditis. Sinus tachycardia remained the most important ECG finding (61, 96.8%) followed by ST-T changes (30, 47.6%), low voltage QRS complexes (23, 36.5%), and premature complexes (11, 17.4%). Sustained arrhythmias were seen in 14/63 (22.2%) of the children (Group A), while the remaining 49 patients were designated as Group B. There were 11 (17.5%) cases with sustained tachyarrhythmias, comprising 5 with supraventricular tachycardia, 4 with ventricular tachycardia, and 2 with atrial flutter/fibrillation. Bradyarrhythmias were seen in 3 patients, including 2 children with atrioventricular block and 1 with severe sinus bradycardia. A longer hospital stay of 18.5 (4.75) days vs. 13 (4) days, P = 0.001), and more ST-T changes [12 (85.7%) vs. 18 (36.73%), P = 0.003] were seen in Group A. Multivariate regression analysis found only the presence of ST-T changes as predictors for arrhythmia. Conclusions A variety of arrhythmias and other ECG changes were commonly seen in children with myocarditis. Sustained arrhythmias were seen in one-fifth of the patients, being associated with ST-T changes and a longer hospital stay.
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Affiliation(s)
- Govind Rasal
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Mrunmayee Deshpande
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Zeeshan Mumtaz
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Milind Phadke
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Ajay Mahajan
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Pratap Nathani
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Yash Lokhandwala
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
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3
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Diagnosis and Management of Myocarditis: An Evidence-Based Review for the Emergency Medicine Clinician. J Emerg Med 2021; 61:222-233. [PMID: 34108120 DOI: 10.1016/j.jemermed.2021.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Myocarditis is a potentially fatal condition that can be misdiagnosed in the emergency department (ED) setting. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of myocarditis, with a focus on emergency clinicians. DISCUSSION Myocarditis occurs when inflammation of the heart musculature causes cardiac dysfunction. Symptoms may range from mild to severe and are often preceded by a viral prodrome. Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is the ideal test in the ED setting. Some patients may also require advanced imaging, though this will often occur during hospitalization or follow-up. Treatment is primarily focused on respiratory and hemodynamic support. Initial hemodynamic management includes vasopressors and inotropes, whereas more severe cases may require an intra-aortic balloon pump, extracorporeal membrane oxygenation, or a ventricular assist device. Nonsteroidal anti-inflammatory drugs should be avoided while intravenous immunoglobulin is controversial. CONCLUSION Myocarditis is a serious condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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4
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Ganga HV. Ventricular arrhythmias and myocardial inflammation detection methods. Int J Cardiol 2019; 282:59. [DOI: 10.1016/j.ijcard.2019.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 11/27/2022]
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Peretto G, Sala S, Rizzo S, De Luca G, Campochiaro C, Sartorelli S, Benedetti G, Palmisano A, Esposito A, Tresoldi M, Thiene G, Basso C, Della Bella P. Arrhythmias in myocarditis: State of the art. Heart Rhythm 2018; 16:793-801. [PMID: 30476544 DOI: 10.1016/j.hrthm.2018.11.024] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Indexed: 01/03/2023]
Abstract
Many kinds of arrhythmias may occur in patients with myocarditis at any stage of the disease. However, compared to the other clinical presentations, arrhythmic myocarditis has been poorly described in the literature. Arrhythmias occurring in either ongoing or previous myocardial inflammation are complex and heterogeneous, and the disease itself is often underdiagnosed, thus limiting data collection and interpretation. However, different from the other clinical presentations, arrhythmic myocarditis requires specific diagnostic, prognostic, and therapeutic considerations. The aim of this review is to critically summarize the state of the art on myocarditis presenting with arrhythmias in terms of epidemiology, etiology, diagnosis, prognosis, and treatment.
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Affiliation(s)
- Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Simone Sala
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefania Rizzo
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University and Hospital of Padua, Padua, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Corrado Campochiaro
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Silvia Sartorelli
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Giulia Benedetti
- Vita-Salute San Raffaele University, Milan, Italy; Cardiac Magnetic Resonance Unit, Department of Radiology and Cardiovascular Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Anna Palmisano
- Cardiac Magnetic Resonance Unit, Department of Radiology and Cardiovascular Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Antonio Esposito
- Cardiac Magnetic Resonance Unit, Department of Radiology and Cardiovascular Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Hospital, Milan, Italy
| | - Gaetano Thiene
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University and Hospital of Padua, Padua, Italy
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University and Hospital of Padua, Padua, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
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Harada M, Motoki H, Kashima Y, Nakamura C, Hashizume N, Kishida D, Imamura H, Kuwahara K. T-wave alternans in a case with systemic lupus erythematosus-related myocarditis. J Cardiol Cases 2018; 18:119-122. [PMID: 30279927 DOI: 10.1016/j.jccase.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 05/17/2018] [Accepted: 05/24/2018] [Indexed: 10/28/2022] Open
Abstract
A 42-year-old woman presented with fever, dyspnea, lower-leg edema, significant pulmonary congestion, pleural effusion, and severely reduced left ventricular contractions. She was resistant to treatment for heart failure, including catecholamines, furosemide, phosphodiesterase III inhibitors, and human atrial natriuretic peptide, and antibiotics failed to reduce her inflammation. She had renal dysfunction and hypocomplementemia and was positive for anti-nuclear and anti-ds-DNA antibodies. The patient was diagnosed with myocarditis and pleurisy associated with systemic lupus erythematosus (SLE). Prednisolone administration improved her general condition, reducing inflammation and improving left ventricular function. On day 1, an electrocardiography (ECG) revealed a T-wave inversion similar to a T-U complex configuration in leads II, aVF, and V3-6. By day 8, however, ECG showed prolonged corrected QT (QTc) and T-wave alternans (alternating beat-to-beat T-wave patterns) in lead V3-6. Careful ECG monitoring should be used to identify potentially fatal ventricular arrhythmias during the recovery phase of SLE-related myocarditis. <Learning objective: This was a case of significant T-wave alternans (TWA) during recovery from systemic lupus erythematosus (SLE)-related myocarditis. Fatal ventricular arrhythmia appears to be a risk during recovery from myocardial damage caused by SLE. Up to now, there have been no published case reports of TWA during this period. Patients with myocarditis should be carefully monitored for arrhythmia, even after ventricular function and inflammation have improved with prednisolone therapy.>.
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Affiliation(s)
- Mikiko Harada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yuichiro Kashima
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Chie Nakamura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan.,Department of Cardiology, Ina Central Hospital, Nagano, Japan
| | - Naoto Hashizume
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Dai Kishida
- Department of Neurology and Rheumatology, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
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7
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Havakuk O, Rezkalla SH, Kloner RA. The Cardiovascular Effects of Cocaine. J Am Coll Cardiol 2017; 70:101-113. [PMID: 28662796 DOI: 10.1016/j.jacc.2017.05.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/26/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.
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Affiliation(s)
- Ofer Havakuk
- Department of Cardiology, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Cardiology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Shereif H Rezkalla
- Department of Cardiology and Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Robert A Kloner
- Department of Cardiology, Keck School of Medicine, University of Southern California, Los Angeles, California; Huntington Medical Research Institute, Los Angeles, California.
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8
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Abstract
UNLABELLED Purpose This study aimed to assess the results of endomyocardial biopsy from the right ventricle to establish the possible cause for drug-refractory arrhythmias in children. Materials and methods We enrolled 19 consecutive young patients with drug-refractory arrhythmia, from 2010 to 2013, who underwent endomyocardial biopsy. Inclusion criteria were as follows: age <18 years with a structurally normal heart or mild changes in a structure of the heart initially diagnosed as arrhythmia-induced cardiomyopathy. Overall, 86 biopsies were performed in 19 patients. Histopathological analysis, immunohistochemistry, and polymerase chain reaction were used for the interpretation of the endomyocardial biopsy. RESULTS The mean age of the patient population was 14.1±2.9 year (range from 7 to 17 years). All these patients had a history of drug-refractory arrhythmia for >5 months (mean 30 months). Patients underwent a complete history investigation, physical examination, laboratory studies, echocardiography, electrocardiography, treadmill test, and Holter monitoring before endomyocardial biopsy; two patients with arrhythmogenic right ventricular dysplasia had implantable cardioverter defibrillator implantation and further appropriate successful device shocks. Myocarditis was diagnosed based on histopathological and immunohistological analyses in nine (47.4%) patients. Polymerase chain reaction was positive for viral genome in four of them; five patients had active myocarditis. Radiofrequency ablation was performed in 17 patients; five out of six (83%) endomyocardial biopsy-proved myocarditis patients had successful radiofrequency ablation. No significant complication was reported during ablation and endomyocardial biopsy. CONCLUSIONS Approximately half of the children with drug-refractory arrhythmia had unsuspected myocarditis according to the results of the endomyocardial biopsy.
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9
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Mammas IN, Theodoridou M, Kramvis A, Thiagarajan P, Gardner S, Papaioannou G, Melidou A, Koutsaki M, Kostagianni G, Achtsidis V, Koutsaftiki C, Calachanis M, Zaravinos A, Greenough A, Spandidos DA. Paediatric Virology: A rapidly increasing educational challenge. Exp Ther Med 2017; 13:364-377. [PMID: 28352303 PMCID: PMC5348700 DOI: 10.3892/etm.2016.3997] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/16/2016] [Indexed: 12/12/2022] Open
Abstract
The '2nd Workshop on Paediatric Virology', which took place on Saturday the 8th of October 2016 in Athens, Greece, provided an overview on recent views and advances on Paediatric Virology. Emphasis was given to HIV-1 management in Greece, a country under continuous financial crisis, hepatitis B vaccination in Africa, treatment options for hepatitis C virus in childhood, Zika virus in pregnancy and infancy, the burden of influenza on childhood, hand-foot-mouth disease and myocarditis associated with Coxsackie viruses. Other general topics covered included a critical evaluation of Paediatric Accident and Emergency viral infections, multimodality imaging of viral infections in children, surgical approaches of otolaryngologists to complex viral infections, new advances in the diagnosis and treatment of viral conjunctivitis and novel molecular diagnostic methods for HPV in childhood. A brief historical overview of the anti-vaccination movement was also provided, as well as presentations on the educational challenge of Paediatric Virology as a new subspecialty of Paediatrics. This review highlights selected lectures and discussions of the workshop.
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Affiliation(s)
- Ioannis N. Mammas
- Department of Clinical Virology, School of Medicine, University of Crete, Heraklion 71003, Greece
| | - Maria Theodoridou
- 1st Department of Paediatrics, ‘Aghia Sophia’ Children's Hospital, University of Athens School of Medicine, Athens 11527, Greece
| | - Anna Kramvis
- Hepatitis Virus Diversity Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Prakash Thiagarajan
- Neonatal Unit, Division for Women's and Children's Health, Noble's Hospital, Douglas, Isle of Man IM4 4RJ, British Isles
| | - Sharryn Gardner
- Department of Children's Accident and Emergency, Southport and Ormskirk Hospital NHS Trust, Ormskirk L39 2AZ, UK
| | - Georgia Papaioannou
- Department of Paediatric Radiology, ‘Mitera’ Children's Hospital, Athens 15123, Greece
| | - Angeliki Melidou
- 2nd Laboratory of Microbiology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Maria Koutsaki
- Paediatric Neurology Division, 3rd Department of Paediatrics, School of Medicine, University of Athens, ‘Attikon’ University Hospital, Athens 12462, Greece
| | - Georgia Kostagianni
- Department of Otorhinolaryngology - Head and Neck Surgery, ‘Triassio’ General Hospital, Elefsina 19200, Greece
| | - Vassilis Achtsidis
- Department of Ophthalmology, Royal Cornwall Hospitals, Truro, Cornwall TR1 3LQ, UK
| | - Chryssie Koutsaftiki
- Paediatric Intensive Care Unit (PICU), ‘Penteli’ Children's Hospital, Penteli 15236, Greece
| | - Marcos Calachanis
- Department of Paediatric Cardiology, ‘Penteli’ Children's Hospital, Penteli 15236, Greece
| | - Apostolos Zaravinos
- Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia 1516, Cyprus
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, King's College London, London SE5 9RS, UK
| | - Demetrios A. Spandidos
- Department of Clinical Virology, School of Medicine, University of Crete, Heraklion 71003, Greece
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Toll-like receptor 4 activation promotes cardiac arrhythmias by decreasing the transient outward potassium current (Ito) through an IRF3-dependent and MyD88-independent pathway. J Mol Cell Cardiol 2014; 76:116-25. [PMID: 25169970 DOI: 10.1016/j.yjmcc.2014.08.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/31/2014] [Accepted: 08/15/2014] [Indexed: 11/21/2022]
Abstract
Cardiac arrhythmias are one of the main causes of death worldwide. Several studies have shown that inflammation plays a key role in different cardiac diseases and Toll-like receptors (TLRs) seem to be involved in cardiac complications. In the present study, we investigated whether the activation of TLR4 induces cardiac electrical remodeling and arrhythmias, and the signaling pathway involved in these effects. Membrane potential was recorded in Wistar rat ventricle. Ca(2+) transients, as well as the L-type Ca(2+) current (ICaL) and the transient outward K(+) current (Ito), were recorded in isolated myocytes after 24 h exposure to the TLR4 agonist, lipopolysaccharide (LPS, 1 μg/ml). TLR4 stimulation in vitro promoted a cardiac electrical remodeling that leads to action potential prolongation associated with arrhythmic events, such as delayed afterdepolarization and triggered activity. After 24 h LPS incubation, Ito amplitude, as well as Kv4.3 and KChIP2 mRNA levels were reduced. The Ito decrease by LPS was prevented by inhibition of interferon regulatory factor 3 (IRF3), but not by inhibition of interleukin-1 receptor-associated kinase 4 (IRAK4) or nuclear factor kappa B (NF-κB). Extrasystolic activity was present in 25% of the cells, but apart from that, Ca(2+) transients and ICaL were not affected by LPS; however, Na(+)/Ca(2+) exchanger (NCX) activity was apparently increased. We conclude that TLR4 activation decreased Ito, which increased AP duration via a MyD88-independent, IRF3-dependent pathway. The longer action potential, associated with enhanced Ca(2+) efflux via NCX, could explain the presence of arrhythmias in the LPS group.
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Crosson JE, Callans DJ, Bradley DJ, Dubin A, Epstein M, Etheridge S, Papez A, Phillips JR, Rhodes LA, Saul P, Stephenson E, Stevenson W, Zimmerman F. PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart. Heart Rhythm 2014; 11:e55-78. [PMID: 24814375 DOI: 10.1016/j.hrthm.2014.05.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 01/02/2023]
Affiliation(s)
- Jane E Crosson
- Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David J Callans
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anne Dubin
- Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, California
| | | | - Susan Etheridge
- University of Utah and Primary Children's Medical Center, Salt Lake City, Utah
| | - Andrew Papez
- Phoenix Children's Hospital/Arizona Pediatric Cardiology Consultants Phoenix, Arizona
| | | | | | - Philip Saul
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | | | - William Stevenson
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frank Zimmerman
- Advocate Heart Institute for Children Advocate Children's Hospital, Oak Lawn, Illinois.
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12
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Miyake CY, Teele SA, Chen L, Motonaga KS, Dubin AM, Balasubramanian S, Balise RR, Rosenthal DN, Alexander ME, Walsh EP, Mah DY. In-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. Am J Cardiol 2014; 113:535-40. [PMID: 24332245 DOI: 10.1016/j.amjcard.2013.10.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 10/23/2013] [Accepted: 10/23/2013] [Indexed: 11/26/2022]
Abstract
Cardiac arrhythmias are a complication of myocarditis. There are no large studies of in-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. This was a retrospective 2-center review of patients ≤21 years hospitalized with acute myocarditis from 1996 to 2012. Fulminant myocarditis was defined as the need for inotropic support within 24 hours of presentation. Acute arrhythmias occurred at presentation and subacute after admission. Eighty-five patients (59% men) presented at a median age of 10 years (1 day to 18 years). Arrhythmias occurred in 38 patients (45%): 16 acute, 12 subacute, and 9 acute and subacute (1 onset unknown). Arrhythmias were associated with low voltages on the electrocardiogram (14 of 34, 41% vs 6 of 47, 13%; odds ratio [OR] 4.78, 95% confidence interval [CI] 1.60 to 14.31) and worse outcome (mechanical support, orthotopic heart transplant, or death; OR 7.59, 95% CI 2.61 to 22.07) but were not statistically significantly associated with a fulminant course, ST changes, initial myocardial function, lactate, creatinine level, C-reactive protein and/or erythrocyte sedimentation rate, or troponin I level, after adjusting for multiple comparisons. Subacute arrhythmias were associated with preceding ST changes (10 of 15, 67% vs 15 of 59, 25%, OR 5.87, 95% CI 1.73 to 19.93). All patients surviving to discharge had arrhythmia resolution or control before discharge (10 on antiarrhythmic), with 1 exception (patient with complete heart block requiring a pacemaker). At 1-year follow-up, there were 3 recurrences of ventricular arrhythmias, but no arrhythmia-related mortality. In conclusion, arrhythmias are common in pediatric patients with myocarditis, occurring in nearly 1/2 of all hospitalized children and are associated with a worse outcome. Early identification of subacute arrhythmias using electrocardiographic changes may help management. A majority of patients do not require continued postdischarge arrhythmia treatment.
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13
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Russo AD, Casella M, Pieroni M, Pelargonio G, Bartoletti S, Santangeli P, Zucchetti M, Innocenti E, Di Biase L, Carbucicchio C, Bellocci F, Fiorentini C, Natale A, Tondo C. Drug-Refractory Ventricular Tachycardias After Myocarditis. Circ Arrhythm Electrophysiol 2012; 5:492-8. [DOI: 10.1161/circep.111.965012] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background—
Ventricular tachycardia (VT) is a significant therapeutic challenge in patients with myocarditis. This study aimed to assess the efficacy and safety of radiofrequency catheter ablation (RFCA) of VT in patients with myocarditis.
Methods and Results—
We enrolled 20 patients (15 men; age, 42 [28–52] years) with a history of biopsy-proven viral myocarditis and drug-refractory VT; 5 patients presented with electrical storm. The median left ventricular ejection fraction was 55% (45–60%). All patients underwent endocardial RFCA with an irrigated catheter, using contact electroanatomic mapping. Recurrence of sustained VT after endocardial RFCA was treated with additional epicardial RFCA. Endocardial RFCA was acutely successful in 14 patients (70%) while in the remaining 6 (30%) clinical VT was successfully ablated by epicardial RFCA. In 1 patient, hemodynamic instability required an intra-aortic balloon pump to complete RFCA. No major complication occurred during or after RFCA. Over a median follow-up time of 28 (11–48) months, 18 patients (90%) remained free of sustained VT; 2 patients (10%, both with baseline left ventricular ejection fraction ≤35%) died of acute heart failure unrelated to ventricular arrhythmias.
Conclusions—
In patients with myocarditis, RFCA of drug-refractory VT is feasible, safe, and effective. Epicardial RFCA should be considered as an important therapeutic option to increase success rate.
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Affiliation(s)
- Antonio Dello Russo
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Michela Casella
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Maurizio Pieroni
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Gemma Pelargonio
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Stefano Bartoletti
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Pasquale Santangeli
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Martina Zucchetti
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Ester Innocenti
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Luigi Di Biase
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Corrado Carbucicchio
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Fulvio Bellocci
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Cesare Fiorentini
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Andrea Natale
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
| | - Claudio Tondo
- From the Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy (A.D.R., M.C., S.B., M.Z., E.I., C.C., C.F., C.T.); the Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy (M.P., G.P., F.B.); Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX (P.S., L.D.B., A.N.); University of Foggia, Foggia, Italy (L.D.B.); the Department of Biomedical Engineering, University of Texas, Austin, TX (L.D.B., A.N.); and the
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14
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Kim HJ, Yoo GH, Kil HR. Clinical outcome of acute myocarditis in children according to treatment modalities. KOREAN JOURNAL OF PEDIATRICS 2010; 53:745-52. [PMID: 21189950 PMCID: PMC3004486 DOI: 10.3345/kjp.2010.53.7.745] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 02/17/2010] [Accepted: 03/17/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE There is currently little evidence to support intravenous immune globulin (IVIG) therapy for pediatric myocarditis. The purpose of our retrospective study was to assess the effects of IVIG therapy in patients with presumed myocarditis on survival and recovery of ventricular function and to determine the factors associated with its poor outcome. METHODS We reviewed all consecutive cases of patients with myocarditis with left ventricular dysfunction verified by echocardiogram who had visited 3 university hospitals between January 2000 and September 2009. These patients were divided into 2 groups. Group 1 consisted of 23 patients (69.6%) who received IVIG alone or IVIG in combination with steroids, and group 2 consisted of 10 patients (30.3%) who received neither IVIG nor other immunosuppressive agents. Clinical manifestations, laboratory results, echocardiographic findings, and outcomes were compared between these 2 groups. RESULTS One year after the initial presentation, the difference in the probability of survival did not show statistical significance in IVIG-treated patients (P=0.607). Of the echocardiographic parameters on admission, a shortening fraction of less than 15% was associated with unremitting cardiac failure. Furthermore, anemic patients were more likely to have elevated N-terminal fragment levels of the B-type natriuretic peptide (NT-proBNP) in the progressed group (P=0.036). CONCLUSION There was no difference between the IVIG-treated patients and the control patients in the degree of recovery of left ventricular function and survival. Prospective, randomized, clinical studies are needed to elucidate the effects of IVIG treatment during the acute stage of myocarditis on ultimate outcomes.
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Affiliation(s)
- Hyun Jung Kim
- Department of Pediatrics, Eulji University School of Medicine, Daejeon, Korea
| | - Gyeong-Hee Yoo
- Department of Pediatrics, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Hong Ryang Kil
- Department of Pediatrics, Chungnam University School of Medicine, Daejeon, Korea
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15
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West nile virus myocarditis causing a fatal arrhythmia: a case report. CASES JOURNAL 2009; 2:7147. [PMID: 19829922 PMCID: PMC2740101 DOI: 10.1186/1757-1626-2-7147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/16/2009] [Indexed: 11/10/2022]
Abstract
West Nile Virus is one of the most frequently reported etiologies of viral encephalitis in the USA. West Nile Virus infections among hospitalized patients manifests most commonly as neuro-invasive disease. West Nile Virus has also been reported to cause myocarditis. Arrhythmia is not an uncommon occurrence in viral myocarditis. As cases of West Nile Virus increase, it is important that the index of suspicion also increase for this uncommon complication. Physicians who are caring for West Nile Virus-infected patients need to be aware of the possibility of West Nile Virus -related myocarditis. The question arises whether a patient with an established diagnosis of West Nile Virus -meningoencephalitis should be under continuous cardiac monitoring, bearing in mind the rare, but fatal, complication of cardiac arrhythmia secondary to viral myocarditis. We present a case report of a 65-year-old man who initially presented with fever, blurry vision, and decreased oral intake who subsequently suffered a fatal arrhythmia; further laboratory tests and autopsy findings revealed the patient likely had developed encephalitis and myocarditis secondary to West Nile Virus infection.
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16
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Sharma JR, Sathanandam S, Rao SP, Acharya S, Flood V. Ventricular tachycardia in acute fulminant myocarditis: medical management and follow-up. Pediatr Cardiol 2008; 29:416-9. [PMID: 17876653 DOI: 10.1007/s00246-007-9044-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The combination of ventricular tachycardia (VT) and severe left ventricular dysfunction presents a serious challenge in management of acute fulminant myocarditis (AFM). We report a case of a 17-month-old girl with AFM, presented with hypotension and VT, successfully treated with respiratory and inotropic support, high-dose intravenous immunoglobulin, and amiodarone. The myocardial function improved significantly within 2 weeks of treatment. The clinical course was complicated by significant amiodarone-induced hepatotoxicity, disseminated intravascular coagulation, and deep-vein thrombosis. She was later diagnosed with congenital dysfibrinogenemia and treated with chronic Lovenox therapy.
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Affiliation(s)
- J R Sharma
- Division of Pediatric Cardiology, Hematology and Intensive Care, Department of Pediatrics, The Children's Hospital at Downstate/State University of New York, 450, Clarkson Avenue, Brooklyn, NY 11203, USA.
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17
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Sestito A, Pardeo M, Sgueglia GA, Natale L, Delogu A, Infusino F, De Rosa G, Bellocci F, Crea F, Lanza GA. Cardiac magnetic resonance of healthy children and young adults with frequent premature ventricular complexes. J Cardiovasc Med (Hagerstown) 2007; 8:692-8. [PMID: 17700398 DOI: 10.2459/jcm.0b013e3280103948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess whether magnetic resonance imaging could detect any cardiac morphological or functional myocardial alterations in healthy children and young adults with ventricular arrhythmias. METHODS Twenty-three subjects (14 male, mean age 15.6 +/- 6.5 years) with frequent (> or =30/h) premature ventricular complexes (PVCs) on Holter monitoring and normal echocardiographic and electrocardiographic findings underwent cardiac magnetic resonance (CMR) on a 1.5T scanner and an exercise stress test. Subjects were also followed up for a period of 71 +/- 24 months. RESULTS CMR showed no evidence of structural cardiac abnormalities, but functional assessment revealed significant impairment in 17 subjects (74%): mild to moderate right ventricular enlargement was found in all of these subjects associated with a mild reduction of ventricular function in five cases (22%) and mild free wall and/or apex contraction abnormalities in eight subjects (35%). PVCs persisted during stress test in three subjects (13%) and disappeared in 19 (83%). No serious cardiac event was observed during the follow-up. CONCLUSIONS Our study shows that subjects with PVCs without detectable electrocardiographic and echocardiographic abnormalities frequently exhibit functional impairment of the right ventricle at CMR, potentially responsible for ventricular arrhythmias. Although the causes of these abnormalities remain to be elucidated, the long-term outcome of these subjects is excellent.
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Affiliation(s)
- Alfonso Sestito
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
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18
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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19
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Canter CE. Therapy for pediatric myocarditis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2005; 7:411-7. [PMID: 16138960 DOI: 10.1007/s11936-005-0025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pediatric myocarditis is most often associated with the acute or subacute onset of congestive heart failure in a previously healthy child. Myocarditis presenting with acute, severe symptomatology, termed fulminant myocarditis, has a high rate of recovery. Aggressive supportive care is indicated in fulminant myocarditis, including mechanical circulatory support. For subacute heart failure, supportive care remains the mainstay of therapy for myocarditis. A number of uncontrolled pediatric studies using both immunosuppressive therapy and/or immunomodulating therapy with intravenous gamma globulin have suggested these therapies are safe and useful in treating pediatric myocarditis. However, translating these results into recommended, routine therapy for pediatric myocarditis is complicated by the high rate of spontaneous improvement of myocarditis with supportive care, and the lack of demonstrable benefit for immunosuppressive and immunomodulating therapies in blinded, randomized, placebo-controlled trials in adult myocarditis. Heart transplantation remains the final therapeutic option for children with myocarditis and intractable severe heart failure.
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Affiliation(s)
- Charles E Canter
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Abstract
CONTEXT Electronic medical devices (EMDs) with downloadable memories, such as implantable cardiac pacemakers, defibrillators, drug pumps, insulin pumps, and glucose monitors, are now an integral part of routine medical practice in the United States, and functional organ replacements, such as the artificial heart, pancreas, and retina, will most likely become commonplace in the near future. Often, EMDs end up in the hands of the pathologist as a surgical specimen or at autopsy. No established guidelines for systematic examination and reporting or comprehensive reviews of EMDs currently exist for the pathologist. OBJECTIVE To provide pathologists with a general overview of EMDs, including a brief history; epidemiology; essential technical aspects, indications, contraindications, and complications of selected devices; potential applications in pathology; relevant government regulations; and suggested examination and reporting guidelines. DATA SOURCES Articles indexed on PubMed of the National Library of Medicine, various medical and history of medicine textbooks, US Food and Drug Administration publications and product information, and specifications provided by device manufacturers. STUDY SELECTION Studies were selected on the basis of relevance to the study objectives. DATA EXTRACTION Descriptive data were selected by the author. DATA SYNTHESIS Suggested examination and reporting guidelines for EMDs received as surgical specimens and retrieved at autopsy. CONCLUSIONS Electronic medical devices received as surgical specimens and retrieved at autopsy are increasing in number and level of sophistication. They should be systematically examined and reported, should have electronic memories downloaded when indicated, will help pathologists answer more questions with greater certainty, and should become an integral part of the formal knowledge base, research focus, training, and practice of pathology.
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Affiliation(s)
- James B Weitzman
- Department of Pathology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.
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22
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Dancea AB. Myocarditis in infants and children: A review for the paediatrician. Paediatr Child Health 2001; 6:543-5. [PMID: 20084124 PMCID: PMC2805590 DOI: 10.1093/pch/6.8.543] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical myocarditis is uncommon in infants and children. The most common pathogen is Coxsackievirus B. The offending agent triggers an immune response, which results in myocardial edema with subsequent impairment of systolic and diastolic function. Newborns and infants are more severely affected because the immature myocardium has limited ways of adapting to an acute insult. Children typically present with sinus tachycardia and gallop on auscultation, cardiomegaly on chest x-ray and small voltages on electrocardiogram. The echocardiogram shows reduced ventricular function. Viral studies can isolate the pathogen. Myocardial biopsy is useful diagnostically, but carries a significant risk for the sick infant. The first line of treatment includes measures such as rest, oxygen and diuretics. Inotropic agents are useful in moderate to severe heart failure. The role of immunosuppressive therapy is not yet clearly established in the paediatric age group. Prognosis is guarded in newborns but more favourable in older children.
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Affiliation(s)
- Adrian Bogdan Dancea
- Division of Pediatric Cardiology, Montreal Children’s Hospital, McGill University, Montreal, Quebec
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23
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Lee KJ, McCrindle BW, Bohn DJ, Wilson GJ, Taylor GP, Freedom RM, Smallhorn JF, Benson LN. Clinical outcomes of acute myocarditis in childhood. Heart 1999; 82:226-33. [PMID: 10409542 PMCID: PMC1729152 DOI: 10.1136/hrt.82.2.226] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe clinical outcomes of a paediatric population with histologically confirmed lymphocytic myocarditis. DESIGN A retrospective review between November 1984 and February 1998. SETTING A major paediatric tertiary care hospital. PATIENTS 36 patients with histologically confirmed lymphocytic myocarditis. MAIN OUTCOME MEASURES Survival, cardiac transplantation, recovery of ventricular function, and persistence of dysrhythmias. RESULTS Freedom from death or cardiac transplantation was 86% at one month and 79% after two years. Five deaths occurred within 72 hours of admission, and one late death at 1.9 years. Extracorporeal membrane oxygenation support was used in four patients, and three patients underwent heart replacement. 34 patients were treated with intravenous corticosteroids. In the survivor/non-cardiac transplantation group (n = 29), the median follow up was 19 months (range 1.2-131.6 months), and the median period for recovery of a left ventricular ejection fraction to > 55% was 2.8 months (range 0-28 months). The mean (SD) final left ventricular ejection and shortening fractions were 66 (9)% and 34 (8)%, respectively. Two patients had residual ventricular dysfunction. No patient required antiarrhythmic treatment. All survivors reported no cardiac symptoms or restrictions in physical activity. CONCLUSIONS Our experience documents good outcomes in paediatric patients presenting with acute heart failure secondary to acute lymphocytic myocarditis treated with immunosuppression. Excellent survival and recovery of ventricular function, with the absence of significant arrhythmias, continued cardiac medications, or restrictions in physical activity were the normal outcomes.
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Affiliation(s)
- K J Lee
- Division of Cardiology, Hospital for Sick Children, 555 University Avenue,Toronto, Ontario M5G 1X8, Canada
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Drago F, Mazza A, Gagliardi MG, Bevilacqua M, Di Renzi P, Calzolari A, Francalanci P, Boldrini R, Bosman C, Di Liso G, Ragonese P. Tachycardias in children originating in the right ventricular outflow tract: lack of clinical features predicting the presence and severity of the histopathological substrate. Cardiol Young 1999; 9:273-9. [PMID: 10386696 DOI: 10.1017/s1047951100004935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim was to determine whether the clinical features of tachycardias originating from the right ventricular outflow tract in children with an apparently normal heart could predict the presence and the severity of the histopathological substrate. Thirteen children (median age 6 years; range 6 months-12 years) with tachycardia originating from the right ventricular outflow tract of apparently normal hearts, were assessed by echocardiography, heart catheterization with angiography, endomyocardial biopsy (13 patients) and magnetic resonance imaging (MRI) (nine patients). Tachycardia was symptomatic in six and sustained in nine. Endomyocardial biopsy and MRI revealed acute myocarditis in five patients (38%), fatty infiltration of the right ventricle in two (15%), and minor histologic abnormalities in three (23%). Myocarditis was diagnosed in three of nine patients with sustained ventricular tachycardia, as opposed to two of four with non-sustained tachycardia (p = NS); in three of six symptomatic versus two of seven asymptomatic patients (p = NS); and in two of eight patients in whom ventricular tachycardia was induced during exercise testing as opposed to one of three in which it was not inducible (p = NS). A histopathological substrate was found in six of nine patients with sustained ventricular tachycardia, and in all four with non-sustained tachycardia (p = NS); in five of six patients with symptoms versus five of seven asymptomatic patients (p = NS); and in five of eight with inducible ventricular tachycardia during exercise testing versus all three in whom it was not inducible (p = NS). The mean rate of tachycardia was 184+/-39 beats min(-1) in patients with myocarditis, as opposed to 171+/-48 in patients without myocarditis (p = NS); and 163+/-33 in patients with a histopathological substrate compared with 210+/-65 in patients without a histopathological substrate (p = NS). It is concluded that a histopathological substrate is present in the greater majority of children affected by the so-called right ventricular outflow tract tachycardia, but that the clinical features of the tachycardia do not predict the presence and the severity of this histopathological substrate.
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Affiliation(s)
- F Drago
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Ges-Children's Hospital, Rome, Italy
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Felices Nieto A, Pavón García M, Alvarez Leiva C, Herrera Rojas D, Olavarría Govantes L, Giménez Raurell J. [Ventricular fibrillation and myocarditis]. Rev Esp Cardiol 1998; 51:600-3. [PMID: 9711110 DOI: 10.1016/s0300-8932(98)74795-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a case of ventricular fibrillation with subacute myocarditis as the only underlying pathological abnormality in a 9-year-old child. The patient died suddenly after a follow-up of 13 years, despite the apparent control of the arrhythmia.
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Affiliation(s)
- A Felices Nieto
- Unidad de Medicina Intensiva, Hospital Militar Universitario Vigil de Quiñones, Sevilla
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