Recurrence of giant cell myocarditis in cardiac allograft

Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review

Giant cell myocarditis (GCM) is a rare, often rapidly progressive, and potentially fatal disease because of myocardium inflammation due to the infiltration of giant cells triggered by infectious as well as non-infectious etiologies. Several studies have reported that GCM can occur in patients of all ages but is more commonly found in adults. It is relatively more common among African American and Hispanic patients than in the White population. Early diagnosis and treatment are critical. Electrocardiogram (EKG), complete blood count, erythrocyte sedimentation rate, C-reactive protein, and cardiac biomarkers such as troponin and brain natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (MRI), myocardial biopsy, and myocardial gene profiling are useful diagnostic tools. Current research has identified several potential biomarkers for GCM, including myocarditis-associated immune cells, cytokines, and other chemicals. The standard of care for GCM includes aggressive immunosuppressive therapy with corticosteroids and immunomodulatory agents like rituximab, cyclosporine, and infliximab, which have shown promising results in GCM by balancing the immune system and preventing the attack on healthy tissues, resulting in the reduction of inflammation, promotion of healing, and decreasing the necessity for cardiac transplantation. Without immunosuppression, the chance of mortality or cardiac surgery was 100%. Multiple studies have revealed that a treatment combination of corticosteroids and immunomodulatory agents is superior to corticosteroids alone. Combination therapy significantly increased transplant-free survival (TFS) and decreased the likelihood of heart transplantation, hence improving overall survival. It is important to balance the benefits of immunosuppression with its potentially adverse effects. In conclusion, immunomodulatory therapy adds significant long-term survival benefits to GCM.

Recurrent giant cell myocarditis after heart transplant: a case report

Background

Giant cell myocarditis (GCM) is a rare but well-known cause of fulminant myocarditis. Despite optimal medical therapy, many patients progress to orthotopic heart transplant (OHT). We present a case of recurrent GCM following OHT, including complex considerations in patient management and infectious sequelae.

Case summary

A 33-year-old previously healthy male presented with 2 months of worsening shortness of breath. Transthoracic echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 30–35%. After ruling out an ischaemic aetiology, he was discharged on guideline-directed medical therapy and later presented with productive cough, worsening dyspnoea on exertion, and diarrhoea. He was found to have elevated troponins and N-terminal pro-brain natriuretic peptide, lactic acidosis, progression of severe bi-ventricular dysfunction on TTE and right heart catheterization, and low cardiac index (1.0 L/min/m2) requiring inotropes. He then required left ventricular assist device as a bridge to OHT. Pathology of the apical core diagnosed GCM as the cause of his fulminant heart failure. He eventually underwent heart transplantation, which was complicated by recurrent GCM. Treatment required intensification of his immunosuppressive regimen, which led to multiple infectious sequelae including norovirus, Shiga-like toxin producing Escherichia coli, and disseminated nocardia of the lung and brain. As of the most recent follow-up, the patient is currently clinically stable.

Discussion

Although recurrent GCM after OHT has been reported in the literature, the prognosis is not well understood and there are no clear guidelines regarding management. This case summarizes clinical considerations, treatment strategies, and adverse effects of recurrent GCM treatment.

Short- and long-term outcomes after heart transplantation in cardiac sarcoidosis and giant-cell myocarditis: a systematic review and meta-analysis

Heart transplantation (HTx) is a valid therapeutic option for end-stage heart failure secondary to cardiac sarcoidosis (CS) or giant-cell myocarditis (GCM). However, post-HTx outcomes in patients with inflammatory cardiomyopathy (ICM) have been poorly investigated. We searched PubMed, Scopus, Science Citation Index, EMBASE, and Google Scholar, screened the gray literature, and contacted experts in the field. We included studies comparing post-HTx survival, acute cellular rejection, and disease recurrence in patients with and without ICM. Data were synthesized by a random‐effects meta‐analysis. We screened 11,933 articles, of which 14 were considered eligible. In a pooled analysis, post-HTx survival was higher in CS than non-CS patients after 1 year (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.60–1.17; I² = 0%) and 5 years (RR 0.72, 95% CI 0.52–0.91; I² = 0%), but statistically significant only after 5 years. During the first-year post-HTx, the risk of acute cellular rejection was similar for patients with and without CS, but after 5 years, it was lower in those with CS (RR 0.38, 95% CI 0.03–0.72; I² = 0%). No difference in post-HTx survival was observed between patients with and without GCM after 1 year (RR 1.16, 95% CI 0.05–2.28; I² = 0%) or 5 years (RR 0.98, 95% CI 0.42–1.54; I² = 0%). During post-HTx follow-up, recurrence of CS and GCM occurred in 5% and 8% of patients, respectively. Post-HTx outcomes in patients with CS and GCM are comparable with cardiac recipients with other heart failure etiologies. Patients with ICM should not be disqualified from HTx.

Management of Patients With Giant Cell Myocarditis: JACC Review Topic of the Week

Giant cell myocarditis is a rare, often rapidly progressive and potentially fatal, disease due to T-cell lymphocyte-mediated inflammation of the myocardium that typically affects young and middle-aged adults. Frequently, the disease course is marked by acute heart failure, cardiogenic shock, intractable ventricular arrhythmias, and/or heart block. Diagnosis is often difficult due to its varied clinical presentation and overlap with other cardiovascular conditions. Although cardiac biomarkers and multimodality imaging are often used as initial diagnostic tests, endomyocardial biopsy is required for definitive diagnosis. Combination immunosuppressive therapy, along with guideline-directed medical therapy, has led to a paradigm shift in the management of giant cell myocarditis resulting in an improvement in overall and transplant-free survival. Early diagnosis and prompt management can decrease the risk of transplantation or death, which remain common in patients who present with cardiogenic shock.

Giant cell myositis associated with concurrent myasthenia gravis: a case-based review of the literature

The term “giant cell myositis” has been used to refer to muscle diseases characterized histologically by multinucleated giant cells. Myasthenia gravis is an autoimmune neuromuscular junction disorder. The rare concurrence of giant cell myositis with myasthenia gravis has been reported; however, the clinical and histological features have varied widely. Here, we present such a case and a review of the literature. An 82-year-old woman admitted for subacute, progressive, proximal muscle weakness developed acute-onset dysphagia, dysphonia, and respiratory distress 5 days after admission. Laboratory findings were positive for acetylcholine receptor binding antibodies and striational muscle antibodies against titin. Muscle biopsy demonstrated widespread muscle fiber necrosis with multinucleated giant cells, consistent with giant cell myositis. She died despite treatment with pulse methylprednisolone and plasma exchange. A literature review of the PubMed and Scopus databases from 1944 to 2020 identified 15 additional cases of these co-existing diagnoses. We found that giant cell myositis with myasthenia gravis primarily affects female patients, is typically diagnosed in the 6–7th decades, and is characterized by the presence of thymoma. Muscle histology predominantly shows giant cell infiltrate without granulomas. The onset of myasthenia gravis symptoms may precede, follow, or coincide with symptoms of myositis. Treatment with thymectomy, anticholinesterase inhibitors, or immunosuppressive therapy may lead to favorable clinical outcomes.

Inflammatory cardiomyopathies: short- and long-term outcomes after heart transplantation-a protocol for a systematic review and meta-analysis

Heart transplantation (HTx) for patients with "giant cell myocarditis" (GCM) or "cardiac sarcoidosis" (CS) is still controversial. However, no single center has accumulated enough experience to investigate post-HTx outcome. The primary aim of this systematic review is to identify, appraise, and synthesize existing literature investigating whether patients who have undergone HTx because of GCM or CS have worse outcomes as compared with patients transplanted because of other etiologies. A systematic and comprehensive search will be performed using PubMed, Scopus, Web of Science, EMBASE, and Google Scholar, for studies published up to December 2019. Observational and interventional population-based studies will be eligible for inclusion. The quality of observational studies will be assessed using the Newcastle-Ottawa scale, while the interventional studies will be assessed using the Cochrane Effective Practice Organization of Care tool. The collected evidence will be narratively synthesized; in addition, we will perform a meta-analysis to pool estimates from studies considered to be homogenous. Reporting of the systematic review and meta-analysis will be in accordance with the Meta-analysis of Observational Studies in Epidemiology Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. To our knowledge, this will be the first synthesis of outcomes, including survival, acute cellular rejection, and disease recurrence, in patients with either GCM or CS treated with HTx. Reviewing the suitability of HTx in this population and highlighting areas for further research will benefit both patients and healthcare providers. Trial registration: CRD42019140574.

Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association

Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure. Historically, FM was almost exclusively diagnosed at autopsy. By definition, all patients with FM will need some form of inotropic or mechanical circulatory support to maintain end-organ perfusion until transplantation or recovery. Specific subtypes of FM may respond to immunomodulatory therapy in addition to guideline-directed medical care. Despite the increasing availability of circulatory support, orthotopic heart transplantation, and disease-specific treatments, patients with FM experience significant morbidity and mortality as a result of a delay in diagnosis and initiation of circulatory support and lack of appropriately trained specialists to manage the condition. This scientific statement outlines the resources necessary to manage the spectrum of FM, including extracorporeal life support, percutaneous and durable ventricular assist devices, transplantation capabilities, and specialists in advanced heart failure, cardiothoracic surgery, cardiac pathology, immunology, and infectious disease. Education of frontline providers who are most likely to encounter FM first is essential to increase timely access to appropriately resourced facilities, to prevent multiorgan system failure, and to tailor disease-specific therapy as early as possible in the disease process.

Sudden death in a pediatric heart transplant recipient with peripheral eosinophilia and eosinophilic myocardial infiltrates

Eosinophilia has been rarely reported in pediatric heart transplant recipients and has been suggested to play a role in graft rejection. We report a case of a young female patient with peripheral blood eosinophilia who died suddenly 2 years following ABO-incompatible heart transplantation. She was found at autopsy to have myocardial infiltration of not only T-lymphocytes and macrophages expected in acute cellular rejection but also of eosinophils, B-lymphocytes, and plasma cells indicating myocarditis.

Small steps for idiopathic giant cell myocarditis

Idiopathic giant cell myocarditis (IGCM) is a rare disease causing progressive myocarditis characterized by myocardial necrosis and giant cells. Patients often present with rapidly progressive heart failure, ventricular arrhythmias, and heart block. Without treatment, the disease often results in progressive pump failure requiring urgent cardiac transplantation or the need for mechanical circulatory support. The underlying pathophysiologic mechanisms are not yet defined but appear to involve genetics, autoimmune disorders, and possibly environmental factors such as viruses. Combined immunosuppressive regimens appear to prolong survival from death or cardiac transplant. Nevertheless, cardiac transplant is an effective treatment. The disease can recur in the transplanted heart resulting in death or the need for retransplant.

Usefulness of Rabbit Anti-thymocyte Globulin in Patients With Giant Cell Myocarditis

Giant cell myocarditis (GCM) is an aggressive inflammatory myocardial disease. Immunosuppression is an effective treatment for some cases. However, the duration of action of agents such as muromonab CD3 is short and others such as the calcineurin inhibitors may lead to renal failure. Here we describe the outcome of a novel approach to treatment using rabbit anti-thymocyte globulin (RATG). A retrospective analysis of 6 patients treated with RATG for GCM was performed. Diagnosis was confirmed by endomyocardial biopsy, and RATG was administered with a high dose of corticosteroids. None of the patients had cytokine release syndrome or leukopenia, and 5 had thrombocytopenia (2 of them severe). Only 1 had a serious bleeding event that occurred after implantation of mechanical circulatory support. None developed impaired renal function after the treatment. Five were successfully discharged home with an increase in global left ventricular ejection fraction of 29%. Four are currently alive without recurrent disease, 1 of them after heart transplantation, with a mean follow-up of 970 days (423 to 1,875 days), left ventricular ejection fraction of 53%, and all in current New York Heart Association Classification class ≤II. Only 1 case had GCM recurrence. There were 2 deaths: one because of intracranial bleeding after mechanical circulatory support implantation and the other caused by primary graft dysfunction. In conclusion, patients with GCM can be successfully immunosuppressed with RATG and corticosteroids, thereby avoiding renal impairment. Early thrombocytopenia is the main adverse event. Larger cohorts of patients are necessary to compare the different immunosuppressant strategies available for GCM in a randomized fashion.

Long-term risk of recurrence, morbidity and mortality in giant cell myocarditis

Giant cell myocarditis (GCM) is a rare disorder in which survival beyond 1 year without heart transplantation is uncommon. Long-term follow-up data on those with such survival are lacking. Twenty-six patients with biopsy-proved GCM who survived for >1 year without heart transplantation were identified from a multicenter GCM registry. The incidence of death, transplantation, ventricular assist device placement, and histologically proved disease recurrence was ascertained retrospectively. The rates of recurrent heart failure, ventricular arrhythmias, renal failure, and infectious complications were calculated. The mean age of the cohort was 54.6 ± 13.9 years (65% women). The mean follow-up duration was 5.5 years starting 1 year after diagnosis. There were 3 deaths (12%), 5 heart transplantations (19%), and 1 ventricular assist device placement (4%). Three histologically confirmed recurrences of GCM (12%) occurred between 1.5 and 8 years after diagnosis. Thirteen of 26 patients experienced a total of 30 heart failure episodes ≥1 year after initial diagnosis. There were 23 episodes of elevated creatinine in 12 patients, 41 infectious events in 13 patients, and 19 episodes of ventricular arrhythmias in 6 patients with a total of 144 years of follow-up. Starting 1 year after GCM diagnosis, the combined rate of death, transplantation, ventricular assist device placement, and GCM recurrence was 47% at 5 years. In conclusion, the risk for GCM recurrence continues to ≥8 years after diagnosis.

Long term biventricular support with Berlin Heart Excor in a Septuagenarian with giant-cell myocarditis

Giant-cell myocarditis (GCM) is known as a rare, rapidly progressive, and frequently fatal myocardial disease in young and middle-aged adults. We report about a 76 year old male patient who underwent implantation with a biventricular Berlin Heart Excor system at the age of 74 due to acute biventricular heart failure caused by giant-cell myocarditis. The implantation was without any surgical problems; however, a difficulty was the immunosuppressive therapy after implantation. Meanwhile the patient is 76 years old and lives with circulatory support for about 3 years without major adverse events. Also, in terms of mobility in old age there are no major limitations. It seems that in even selected elderly patients an implantation of a long term support with the biventricular Berlin Heart Excor is a useful therapeutic option with an acceptable outcome.

When should we consider the diagnosis of giant cell myocarditis? Revisiting "classic" echocardiographic and clinical features of this rare pathology

OBJECTIVES

Giant cell myocarditis is a rare and often fatal disorder. According to the American Heart Association, the American College of Cardiology Foundation, and the European Society of Cardiology scientific statements, an endomyocardial biopsy should be done to exclude giant cell myocarditis in unexplained new-onset heart failure of 2 weeks to 3 months duration associated with dilated left ventricle and new ventricular arrhythmias, or Mobitz type II second-degree, or third-degree atrioventricular heart block.

CASE PRESENTATIONS

Two hundred thirty-five heart transplants were performed since May 1993 at the Institut universitaire de cardiologie et de pneumologie de Quebec, Canada. Giant cell myocarditis was found in the explanted hearts of 5 patients. The preoperative diagnosis of giant cell myocarditis was done by endomyocardial biopsy or at the installation of a left ventricular-assisted device. Patients had symptoms of progressive heart failure of subacute onset. Patients consulted at a mean 32 days after the onset of symptoms. Two patients neither had ventricular arrhythmia nor heart block. Two patients had ventricular arrhythmias and heart block; the other patient had symptomatic heart block. All patients had at least 2 echocardiographies. Two patients had an increase in left ventricular size, enough to reach the criteria of left ventricular dilatation according to the American Society of Echocardiography. During this time, left ventricular ejection fraction showed a rapid decline (mean 37% to 16%).

CONCLUSIONS

Ventricular arrhythmia, heart block, and left ventricular dilatation initially can be absent in many patients having giant cell myocarditis with symptoms of progressive heart failure. Endo-myocardial biopsy should be quickly considered in patients with a rapid and dramatic decline of left ventricular ejection fraction, even in the absence of classic clinical and echocardiographic features of giant cell myocarditis to rapidly obtain the diagnosis of this rare but lethal disease.

Current treatment options in (peri)myocarditis and inflammatory cardiomyopathy

In inflammatory dilated cardiomyopathy and myocarditis there is--apart from heart failure and antiarrhythmic therapies--no alternative to an aetiologically driven specific treatment. Prerequisite are noninvasive and invasive biomarkers including endomyocardial biopsy and PCR on cardiotropic agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy including the genetic background, the predisposition for heart failure and inflammation. It analyses the epidemiologic shift in pathogenetic agents in the last 20 years, the role of innate and aquired immunity including the T- and B-cell driven immune responses. The phases and clinical faces of myocarditis are summarized. Up-to-date information on current treatment options starting with heart failure and antiarrhythmic therapy are provided. Although inflammation can resolve spontaneously, specific treatment directed to the causative aetiology is often required. For fulminant, acute and chronic autoreactive myocarditis immunosuppressive treatment is beneficial, while for viral cardiomyopathy and myocarditis ivIg can resolve inflammation and is as successful as interferon therapy in enteroviral and adenoviral myocarditis. For Parvo B19 and HHV6 myocarditis eradication of the virus is still a problem by any of these treatment options. Finally, the potential of stem cell therapy has to be tested in future trials. In virus-negative, autoreactive perimyocardial disease a locoregional approach with intrapericardial instillation of high local doses of triamcinolone acetate has been shown to be highly efficient and with few systemic side-effects.

Recurrent myocarditis--an important mimic of ischaemic myocardial infarction

Patients presenting with a syndrome of chest pain, elevated cardiac enzyme levels with or without electrocardiogram changes are a common diagnostic and management problem in cardiology. Most commonly, this is due to ischaemic myocardial infarction secondary to coronary artery disease. However, when coronary angiography does not demonstrate any obstructive coronary artery lesion, the diagnosis of myocarditis should be considered. Cardiac magnetic resonance imaging is helpful towards making this diagnosis. Here, we describe the first reported Australian cases of recurrent myocarditis presenting with ischaemic chest pain and elevated cardiac enzyme levels. These cases serve as an important reminder to clinicians that myocarditis is an important mimic of ischaemic myocardial infarction.

Giant cell myocarditis with incessant ventricular arrhythmias treated successfully with methylprednisolone and rat antithymocyte globulin

Giant cell myocarditis is an aggressive form of this condition that is typically progressive and unresponsive to usual medical treatment. Here, we describe a 34-year-old patient presenting with incessant ventricular arrhythmias with hemodynamic compromise who required prolonged support in intensive care with an intra-aortic balloon pump (IABP). His Coronary arteries were normal and LV endomyocardial biopsy revealed myocyte necrosis with inflammatory infiltrate of lymphocytes, eosinophils, and giant cells suggestive of giant cell myocarditis. He was successfully treated with pulsed intravenous methylprednisolone and rat antithymocyte globulin (RATG). Despite a good functional cardiac recovery, some months later he developed a fluctuant neck swelling which fine needle aspiration confirmed as tuberculosis.

An unusual case of allograft neutrophilic myocarditis mimicking acute myocardial infarction in a post-heart transplant patient

The clinical presentation of myocarditis is variable and can mimic myocardial infarction. The diagnosis of acute myocarditis is frequently empiric, and is made on the basis of the clinical presentation, electrocardiographic changes, elevated cardiac enzymes, and lack of epicardial coronary artery disease and lymphocytic infiltration on myocardial biopsy. We present an unusual case of a young patient with history of heart transplantation who presented with fever and polyarthritis and developed chest pain along with electrocardiographic changes and troponin elevation with no evidence of coronary artery disease. His myocardial biopsy revealed marked neutrophilic infiltration and no evidence of rejection. The clinical picture was compatible with a rare finding of neutrophilic myocarditis in the allograft, possibly related to a systemic inflammatory process.

Applications of cardiac magnetic resonance in electrophysiology

Contemporary methods for evaluation and treatment of arrhythmia are increasingly dependent upon characterization of the underlying myocardial substrate. Cardiovascular magnetic resonance offers unsurpassed soft tissue resolution capable of visualizing detailed cardiac anatomic features and intra-myocardial barriers to conduction. Non-invasive visualization of such anatomic detail has the potential to improve methods to diagnose, risk stratify, and treat patients with arrhythmia. This review describes a brief overview of the current knowledge on the applications of cardiac magnetic resonance for evaluation and treatment of patients with arrhythmia.

Resolution of giant cell myocarditis after extended ventricular assistance

Lower recurrence rates and improved long-term outcomes are the goal of treatment for giant cell myocarditis (GCM). We describe a case of GCM in an Asian woman who presented with new onset palpitations and syncope. She initially had normal systolic function by echocardiography with magnetic resonance imaging evidence of infiltrative cardiomyopathy. She underwent implantation of a biventricular assist device (BiVAD) because of rapidly deteriorating hemodynamic status. Giant cell myocarditis was diagnosed at that time by surgical biopsy. She was not treated with immunosuppressive therapy because of low likelihood of recovery and concerns for potential infection with the BiVAD in place. She received a heart transplant 12 months later and had extensive fibrosis but no evidence of active GCM in the heart explant. The role of extended BiVAD support in patients with GCM should be further investigated.

MRI to assess arrhythmia and cardiomyopathies: relationship to echocardiography

Cardiomyopathies are a group of diseases that are associated with myocardial dysfunction and/or arrhythmia due to abnormalities of the myocardium. Echocardiography is the most commonly used method for functional evaluation and classification of cardiomyopathy since it is widely available. Magnetic resonance imaging (MRI) has recently emerged as a well-validated diagnostic tool for the understanding and treatment of these conditions. Morphological and functional information can be achieved with a high level of accuracy and reproducibility. This article reviews the applications of MRI in relationship to echocardiography for the diagnosis of cardiomyopathy and arrhythmogenic conditions of the heart.

Intracardiac giant cells after left ventricular assist device placement

Multinucleated giant cells are seen in the heart in several distinct pathologic conditions, including giant cell myocarditis, sarcoidosis and infectious etiologies. We describe the first report of solitary multinucleated giant cells scattered throughout the heart after placement of a left ventricular assist device (LVAD) and transient Candida glabrata infection. The pathologic findings were noted in the explanted heart of a patient undergoing orthotopic cardiac transplantation 7 months after LVAD surgery. The presence of solitary giant cells without adjacent inflammation was a distinct histologic finding in this case. An awareness of this entity is important to avoid making a diagnosis of a more severe giant cell-related pathologic disease, which may recur in a transplanted heart.

Orthotopic cardiac transplantation for the treatment of progressive heart failure caused by idiopathic giant cell myocarditis

We describe a patient with idiopathic giant cell myocarditis who underwent orthotopic cardiac transplantation. On triple immunosuppressive therapy including prednisone, cyclosporine and mycophenolate, the patient has not had recurrence of idiopathic giant cell myocarditis in the transplanted heart in 48 months of follow-up.

Magnetic resonance imaging in the evaluation of non-ischemic cardiomyopathies: current applications and future perspectives

Patients with non-ischemic cardiomyopathy often represent a diagnostic challenge, and correct etiologic diagnosis may influence outcomes. Lately, delayed myocardial enhancement MR imaging has been developed and is currently being used for a growing number of clinical applications. On delayed enhancement MR images, scarring or fibrosis appears as an area of high signal intensity, and the pattern by which this enhancement occurs in the myocardium allows distinction of many different pathologies. In nonischemic cardiomyopathy, the delayed enhancement usually does not occur in a coronary artery distribution and is often midwall rather than subendocardial or transmural. It could also guide myocardial biopsy to an affected area, increasing its yield. Cardiac magnetic resonance imaging has now a definitive role in clinical practice, and its capability to non-invasively provide high resolution images of the heart with good tissue characterization is redefining the understanding of the conditions that can adversely affect the myocardium.

MRI to assess arrhythmia and cardiomyopathies

Cardiovascular magnetic resonance (CMR) is highly precise for morphological and functional analyses of the myocardium, and has been used to assess different types of cardiomyopathies. Its ability to characterize tissue, especially with gadolinium (Gd) delayed-enhancement techniques, has shown promising results for the diagnosis of arrhythmogenic cardiomyopathies. In this review we discuss the background and potential of this approach, as well as its usefulness for assessing arrhythmias and cardiomyopathies.

Transplantation for myocarditis: a controversy revisited

Myocarditis is a major cause of end-stage heart failure and is responsible for up to 10% of cases of idiopathic dilated cardiomyopathy (IDC). Worldwide, approximately 45% of all heart transplants are performed for IDC and up to 8% for myocarditis. Early reports suggested that survival after transplantation for myocarditis was poor and patients had an increased risk of rejection. More recently, larger case series suggest that overall survival after transplantation for myocarditis is similar to survival after transplantation for other causes. However, certain disorders, including cardiac sarcoidosis and giant cell myocarditis (GCM), require heightened surveillance for post-transplantation disease recurrence. We present the case of a 42-year-old man with recurrence of GCM 8 years after transplantation and review the literature on the role of cardiac transplantation for patients with myocarditis.

Total lymphoid irradiation: new therapeutic option for refractory giant cell myocarditis

Idiopathic giant cell myocarditis (GCM) is believed to be a T-lymphocyte-mediated autoimmune disease. Some patients with GCM have a dramatic clinical response to anti-T-cell immunosuppression. However, this response is not uniform and patients often deteriorate rapidly and need a cardiac transplantation within months of diagnosis. Following cardiac transplantation, GCM may recur in the graft but is usually mild and responds to augmentation of immunosuppression. This report is the first description of total lymphoid irradiation (TLI) for the treatment of GCM, which was used in a patient who developed an exceptionally early and severe recurrence of GCM in the cardiac graft that remained refractory to heightened immunosuppression for 4 months. Clinical and histologic remission followed a course of TLI and was maintained for 1 year despite a gradual decrease in immunosuppression. This novel treatment should be considered in all patients with GCM who do not have histologic remission with the currently employed anti-T-cell immunosuppression.

Coronary artery disease obscuring giant cell myocarditis--a case report

A case in which the diagnosis of idiopathic giant cell myocarditis was obscured by the presence of severe coronary artery disease is described. A 47-year-old man presented with recurrent inferior myocardial infarction and complete heart block. Cardiac catheterization confirmed severe 2-vessel disease and left ventricular dysfunction. Incessant ventricular arrhythmia rapidly ensued, which did not respond to anti-arrhythmic therapy and overdrive pacing despite complete surgical revascularization. He eventually died. Autopsy revealed giant cell myocarditis superimposed on coronary artery disease. Acute myocarditis masquerading as myocardial infarction has been well known, but virtually all reported cases had normal coronary arteries. This case illustrated the fact that even in the presence of obvious coronary artery disease the remote possibility of myocarditis should not be entirely disregarded. Although giant cell myocarditis is a rare and frequently fatal disorder, recent studies suggest that combined immunosuppressive therapy may improve the prognosis.

Idiopathic Giant Cell Myocarditis

Idiopathic giant cell myocarditis (IGCM) is an uncommon disorder that is of general importance because it most commonly affects young individuals, is usually fatal without treatment, and may respond to aggressive medical and surgical therapy. IGCM is most often progressive over days to weeks and frequently requires the concurrent management of congestive heart failure, tachyarrhythmias, and heart block. After common causes of heart disease are excluded, the diagnosis must be confirmed by endomyocardial biopsy. Standard pharmacologic therapy for New York Heart Association functional class II to III congestive heart failure due to left ventricular systolic failure includes an angiotensin-converting enzyme inhibitor, a beta-blocker such as carvedilol, and diuretics as needed. We avoid digoxin and reserve inotropic agents for patients whose circulatory requirements cannot be supported with standard oral vasodilators and diuretics. Heart block may require a temporary or permanent pacemaker. Ventricular tachycardia is common and usually is managed chronically with an implantable cardiac defibrillator and antiarrhythmic drugs such as amiodarone. Despite optimal medical management, mechanical support may be required as a temporary bridge to recovery or transplantation. The intra-aortic balloon pump and ventricular assist device have been used successfully for patients with refractory pump failure due to acute IGCM. Heart transplantation is efficacious, with a 71% 5-year survival, despite a 20% to 25% rate of histologic recurrence in surveillance endomyocardial biopsies. The role of aggressive immunosuppression as part of the primary treatment of IGCM is under active investigation. Preliminary data suggest that primary therapy with a regimen that includes muromonab-CD3, cyclosporine, and steroids may significantly improve transplant-free survival.