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Ono R, Iwahana T, Aoki K, Kato H, Okada S, Kobayashi Y. Fulminant Myocarditis with SARS-CoV-2 Infection: A Narrative Review from the Case Studies. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:9000598. [PMID: 38469104 PMCID: PMC10927348 DOI: 10.1155/2024/9000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/13/2024]
Abstract
One of the severe complications of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is myocarditis. However, the characteristics of fulminant myocarditis with SARS-CoV-2 infection are still unclear. We systematically reviewed the previously reported cases of fulminant myocarditis associated with SARS-CoV-2 infection from January 2020 to December 2022, identifying 108 cases. Of those, 67 were male and 41 female. The average age was 34.8 years; 30 patients (27.8%) were ≤20 years old, whereas 10 (9.3%) were ≥60. Major comorbidities included hypertension, obesity, diabetes mellitus, asthma, heart disease, gynecologic disease, hyperlipidemia, and connective tissue disorders. Regarding left ventricular ejection fraction (LVEF) at admission, 93% of the patients with fulminant myocarditis were classified as having heart failure with reduced ejection fraction (LVEF ≤ 40%). Most of the cases were administered catecholamines (97.8%), and mechanical circulatory support (MCS) was required in 67 cases (62.0%). The type of MCS was extracorporeal membrane oxygenation (n = 56, 83.6%), percutaneous ventricular assist device (Impella®) (n = 19, 28.4%), intra-aortic balloon pumping (n = 12, 12.9%), or right ventricular assist device (n = 2, 3.0%); combination of these devices occurred in 20 cases (29.9%). The average duration of MCS was 7.7 ± 3.8 days. Of the 76 surviving patients whose cardiac function was available for follow-up, 65 (85.5%) recovered normally. The overall mortality rate was 22.4%, and the recovery rate was 77.6% (alive: 83 patients, dead: 24 patients; outcome not described: 1 patient).
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Togo Iwahana
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Kaoruko Aoki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Hirotoshi Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Sho Okada
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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Hashmani S, Manla Y, Al Matrooshi N, Bader F. Red Flags in Acute Myocarditis. Card Fail Rev 2024; 10:e02. [PMID: 38464556 PMCID: PMC10918526 DOI: 10.15420/cfr.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 09/02/2023] [Indexed: 03/12/2024] Open
Abstract
Acute myocarditis is an inflammatory disease of the heart that may occur in the setting of infection, immune system activation or exposure to certain drugs. Often, it is caused by viruses, whereby the clinical course is usually benign; however, it may also present with rapidly progressive fulminant myocarditis, which is associated with high morbidity and mortality. This review highlights the critical red flags - from the clinical, biochemical, imaging and histopathological perspectives - that should raise the index of suspicion of acute myocarditis. We also present an illustrative case of a young female patient with rapidly progressive cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation as a bridge to orthotopic heart transplantation. The patient showed no clinical or echocardiographic recovery signs and eventually underwent orthotopic heart transplantation. Furthermore, we elaborate on the classifications of acute myocarditis based on clinical presentation and histopathology classifications, focusing on identifying key red flags that will inform early diagnosis and appropriate management in such challenging cases.
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Affiliation(s)
- Shahrukh Hashmani
- Section of Advance Heart Failure & Transplantation, Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi United Arab Emirates
| | - Yosef Manla
- Section of Advance Heart Failure & Transplantation, Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi United Arab Emirates
| | - Nadya Al Matrooshi
- Section of Advance Heart Failure & Transplantation, Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi United Arab Emirates
| | - Feras Bader
- Section of Advance Heart Failure & Transplantation, Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi United Arab Emirates
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Crisci G, Bobbio E, Gentile P, Bromage DI, Bollano E, Ferone E, Israr MZ, Heaney LM, Polte CL, Cannatà A, Salzano A. Biomarkers in Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Updated Review of the Literature. J Clin Med 2023; 12:7214. [PMID: 38068265 PMCID: PMC10706911 DOI: 10.3390/jcm12237214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 02/15/2024] Open
Abstract
Myocarditis is a disease caused by cardiac inflammation that can progress to dilated cardiomyopathy, heart failure, and eventually death. Several etiologies, including autoimmune, drug-induced, and infectious, lead to inflammation, which causes damage to the myocardium, followed by remodeling and fibrosis. Although there has been an increasing understanding of pathophysiology, early and accurate diagnosis, and effective treatment remain challenging due to the high heterogeneity. As a result, many patients have poor prognosis, with those surviving at risk of long-term sequelae. Current diagnostic methods, including imaging and endomyocardial biopsy, are, at times, expensive, invasive, and not always performed early enough to affect disease progression. Therefore, the identification of accurate, cost-effective, and prognostically informative biomarkers is critical for screening and treatment. The review then focuses on the biomarkers currently associated with these conditions, which have been extensively studied via blood tests and imaging techniques. The information within this review was retrieved through extensive literature research conducted on major publicly accessible databases and has been collated and revised by an international panel of experts. The biomarkers discussed in the article have shown great promise in clinical research studies and provide clinicians with essential tools for early diagnosis and improved outcomes.
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Affiliation(s)
- Giulia Crisci
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Piero Gentile
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy;
| | - Daniel I. Bromage
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Emma Ferone
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Muhammad Zubair Israr
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
| | - Liam M. Heaney
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK;
| | - Christian L. Polte
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
- Department of Clinical Physiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Antonio Cannatà
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Andrea Salzano
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
- Cardiology Unit, AORN A Cardarelli, 80131 Naples, Italy
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Yen PC, Chou W, Chien TW, Jen TH. Analyzing fulminant myocarditis research trends and characteristics using the follower-leading clustering algorithm (FLCA): A bibliometric study. Medicine (Baltimore) 2023; 102:e34169. [PMID: 37390236 PMCID: PMC10313307 DOI: 10.1097/md.0000000000034169] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Myocarditis can be classified into 2 categories: fulminant myocarditis (FM) and nonfulminant myocarditis. FM is the most severe type, characterized by its acute and explosive nature, posing a sudden and life-threatening risk with a high fatality rate. Limited research has been conducted on FM characteristics using cluster analysis. This study introduces the following-leading clustering algorithm (`) as a unique method and utilizes it to generate a dual map and timeline view of FM themes, aiming to gain a better understanding of FM. METHODS The metadata were obtained from the Web of Science (WoS) database using an advanced search strategy based on the topic (TS= (("Fulminant") AND ("Myocarditis"))). The analysis comprised 3 main components: descriptive analytics, which involved identifying the most influential entities using CJAL scores and analyzing publication trends, author collaborations using the FLCA algorithm, and generating a dual map and timeline view of FM themes using the FLCA algorithm. The visualizations included radar plots divided into 4 quadrants, stacked bar and line charts, network charts, chord diagrams, a dual map overlay, and a timeline view. RESULTS The findings reveal that the prominent entities in terms of countries, institutes, departments, and authors were the United States, Huazhong University of Science and Technology (China), Cardiology, and Enrico Ammirati from Italy. A dual map, based on the research category, was created to analyze the relationship between citing and cited articles. It showed that articles related to cells and clinical medicine/surgery were frequently cited by articles in the fields of general health/public/nursing and clinical medicine/surgery. Additionally, a visual timeline view was presented on Google Maps, showcasing the themes extracted from the top 100 cited articles. These visualizations were successfully and reliably generated using the FLCA algorithm, offering insights from various perspectives. CONCLUSION A new FLCA algorithm was utilized to examine bibliometric data from 1989 to 2022, specifically focusing on FM. The results of this analysis can serve as a valuable guide for researchers, offering insights into the thematic trends and characteristics of FM research development. This, in turn, can facilitate and promote future research endeavors in this field.
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Affiliation(s)
- Pei-Chun Yen
- Department of Hepatobiliary Gastroenterology, Chiali Chi-Mei Hospital, Tainan, Taiwan
| | - Willy Chou
- Department of Physical Medicine and Rehabilitation, Chiali Chi-Mei Hospital, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, Chung San Medical University Hospital, Taichung, Taiwan
| | - Tsair-Wei Chien
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Tung-Hui Jen
- Department of Senior Welfare and Service, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- Department of Chinese Medicine, Chi-Mei Medical Center, Tainan, Taiwan
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Bohné M, Bohnen S, Willems S, Klingel K, Kivelitz D, Bahlmann E. Acute Lymphocytic Myocarditis in a Young Male Post-COVID-19. Case Rep Cardiol 2023; 2023:7646962. [PMID: 37397607 PMCID: PMC10310455 DOI: 10.1155/2023/7646962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/10/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Background Lymphocytic myocarditis is a rare form of myocarditis, associated with a high mortality rate due to a high risk of sudden cardiac death. Lymphocytic myocarditis might present as a relevant extrapulmonary manifestation after coronavirus disease 2019 (COVID-19) infection. Case presentation. We report a case of a 26-year-old male with lymphocytic myocarditis, presenting with a 1-month history of increasing fatigue, palpitations, and shortness of breath. Eight weeks before, he was tested positive for SARS-CoV-2. He had received 2-dose schedule of the COVID-19 mRNA vaccine Comirnaty® (BioNTech/Pfizer) 6 months prior to his admission. Diagnostic work-up by echocardiography and cardiac magnetic resonance (CMR) imaging demonstrated a severely reduced left ventricular function and a strong midmyocardial late gadolinium enhancement (LGE). Histology and immunohistology of the endomyocardial biopsies revealed an acute lymphocytic myocarditis. Immunosuppressive therapy with a steroid taper in combination with azathioprine 300 mg/day was initiated. The patient was equipped with a LifeVest®. On day 17, a non-sustained ventricular tachycardia was documented. Follow-up CMR imaging after 3 months showed a slightly improved systolic left ventricular function, and a strong LGE was still detectable. Conclusions The case highlights the significance of recognizing lymphocytic myocarditis correlated to COVID-19. It is important to be vigilant also of a later presentation of cardiomyopathy in patients diagnosed with COVID-19 due to high mortality without immediate support.
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Affiliation(s)
- Mintje Bohné
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Sebastian Bohnen
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Dietmar Kivelitz
- Department of Radiology, Asklepios Clinic St. Georg, Hamburg, Semmelweis University, Budapest, Asklepios CampusHamburg, Germany
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
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Guglin ME, Etuk A, Shah C, Ilonze OJ. Fulminant Myocarditis and Cardiogenic Shock Following COVID-19 Infection Versus COVID-19 Vaccination: A Systematic Literature Review. J Clin Med 2023; 12:jcm12051849. [PMID: 36902636 PMCID: PMC10003085 DOI: 10.3390/jcm12051849] [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: 12/31/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Myocarditis, diagnosed by symptoms and troponin elevation, has been well-described with COVID-19 infection, as well as shortly after COVID-19 vaccination. The literature has characterized the outcomes of myocarditis following COVID-19 infection and vaccination, but clinicopathologic, hemodynamic, and pathologic features following fulminant myocarditis have not been well-characterized. We aimed to compare clinical and pathological features of fulminant myocarditis requiring hemodynamic support with vasopressors/inotropes and mechanical circulatory support (MCS), in these two conditions. METHODS We analyzed the literature on fulminant myocarditis and cardiogenic shock associated with COVID-19 and COVID-19 vaccination and systematically reviewed all cases and case series where individual patient data were presented. We searched PubMed, EMBASE, and Google Scholar for "COVID", "COVID-19", and "coronavirus" in combination with "vaccine", "fulminant myocarditis", "acute heart failure", and "cardiogenic shock". The Student's t-test was used for continuous variables and the χ2 statistic was used for categorical variables. For non-normal data distributions, the Wilcoxon Rank Sum Test was used for statistical comparisons. RESULTS We identified 73 cases and 27 cases of fulminant myocarditis associated with COVID-19 infection (COVID-19 FM) and COVID-19 vaccination (COVID-19 vaccine FM), respectively. Fever, shortness of breath, and chest pain were common presentations, but shortness of breath and pulmonary infiltrates were more often present in COVID-19 FM. Tachycardia, hypotension, leukocytosis, and lactic acidosis were seen in both cohorts, but patients with COVID-19 FM were more tachycardic and hypotensive. Histologically, lymphocytic myocarditis dominated both subsets, with some cases of eosinophilic myocarditis in both cohorts. Cellular necrosis was seen in 44.0% and 47.8% of COVID-19 FM and COVID-19 vaccine FM, respectively. Vasopressors and inotropes were used in 69.9% of COVID-19 FM and in 63.0% of the COVID-19 vaccine FM. Cardiac arrest was observed more in COVID-19 FM (p = 0.008). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for cardiogenic shock was also used more commonly in the COVID-19 fulminant myocarditis group (p = 0.0293). Reported mortality was similar (27.7%) and 27.8%, respectively) but was likely worse for COVID-19 FM as the outcome was still unknown in 11% of cases. CONCLUSIONS In the first series to retrospectively assess fulminant myocarditis associated with COVID-19 infection versus COVID-19 vaccination, we found that both conditions had a similarly high mortality rate, while COVID-19 FM had a more malignant course with more symptoms on presentation, more profound hemodynamic decompensation (higher heart rate, lower blood pressure), more cardiac arrests, and higher temporary MCS requirements including VA-ECMO. In terms of pathology, there was no difference in most biopsies/autopsies that demonstrated lymphocytic infiltrates and some eosinophilic or mixed infiltrates. There was no predominance of young males in COVID-19 vaccine FM cases, with male patients representing only 40.9% of the cohort.
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Affiliation(s)
- Maya E. Guglin
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, IN 46202, USA
- Correspondence: ; Tel.: +317-962-9700; Fax: +317-962-9657
| | - Aniekeme Etuk
- Department of Medicine, Thomas Hospital-Infirmary Health, Fairhope, AL 36532, USA
| | - Chirag Shah
- Department of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Onyedika J. Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, IN 46202, USA
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Moraes FCAD, Santos RRDE, Campos JCD, Mota ACC, Pessoa FR, Sarges DC, Moraes DA, Souza DDSMD. Covid-19 and Heart Involvement: A Systematic Review of Literature. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2023. [DOI: 10.36660/ijcs.20220035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Veronese G, Nonini S, Bottiroli M, Annoni G, Izzo F, Nespoli LF, Corato A, Marianeschi SM, Aresta F, Bramerio MA, Mondino M, Ammirati E. A case of parvovirus B19-associated fulminant myocarditis in an infant successfully treated with immunosuppressive therapy. J Cardiovasc Med (Hagerstown) 2022; 23:697-699. [PMID: 36099078 DOI: 10.2459/jcm.0000000000001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Giacomo Veronese
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan.,Department of Health Sciences, University of Milano-Bicocca, Monza
| | - Sandra Nonini
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Maurizio Bottiroli
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Giuseppe Annoni
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | | | - Luisa F Nespoli
- Pediatric Cardiology, Ospedale dei Bambini 'Vittore Buzzi', Milan, Italy
| | - Alessandra Corato
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | | | - Francesca Aresta
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Manuela A Bramerio
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Michele Mondino
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Enrico Ammirati
- 'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
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Yang W, He X, Wang Z, Lu L, Zhou G, Cheng J, Hao X. Research focus and theme trend on fulminant myocarditis: A bibliometric analysis. Front Cardiovasc Med 2022; 9:935073. [PMID: 36187003 PMCID: PMC9515361 DOI: 10.3389/fcvm.2022.935073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
AimsThis study intends to explore the research focus and trends of fulminant myocarditis (FM) to have a better understanding of the topic.Materials and methodsThe data were downloaded from the Web of Science (WoS) database using the topic (TS) advanced search strategy. Many instruments were used to extract, analyze, and visualize the data, such as Microsoft Excel, HistCite Pro, GunnMap, BibExcel, and VOSviewer.ResultsFrom 1985 to 2022, 726 documents were indexed in the WoS. The United States and Columbia University were the most productive country and institutions. Keywords co-occurrence was carried out and four research themes were identified. In addition, the top three prolific authors, the first three highly cited authors, and the core authors of the author co-citation network were identified. The topics that they kept an eye on were analyzed, and the research areas of key authors were similar to the results of keyword co-occurrence. The hot topics of FM were related to the mechanical circulatory support, etiology, diagnosis, and the disease or therapy associated with FM.ConclusionThis study carried out a systematic analysis of the documents related to FM from 1985 to 2022, which can provide a guideline for researchers to understand the theme trend to promote future research to be carried out.
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Affiliation(s)
- Weimei Yang
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xifei He
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xifei He,
| | - Zhaozhao Wang
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Zhaozhao Wang,
| | - Lijuan Lu
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ge Zhou
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Cheng
- Department of Cardiovascular Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinying Hao
- School of Humanities and Social Sciences, University of Science and Technology of China, Hefei, China
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Ammirati E, Lupi L, Palazzini M, Hendren NS, Grodin JL, Cannistraci CV, Schmidt M, Hekimian G, Peretto G, Bochaton T, Hayek A, Piriou N, Leonardi S, Guida S, Turco A, Sala S, Uribarri A, Van de Heyning CM, Mapelli M, Campodonico J, Pedrotti P, Barrionuevo Sánchez MI, Ariza Sole A, Marini M, Matassini MV, Vourc'h M, Cannatà A, Bromage DI, Briguglia D, Salamanca J, Diez-Villanueva P, Lehtonen J, Huang F, Russel S, Soriano F, Turrini F, Cipriani M, Bramerio M, Di Pasquale M, Grosu A, Senni M, Farina D, Agostoni P, Rizzo S, De Gaspari M, Marzo F, Duran JM, Adler ED, Giannattasio C, Basso C, McDonagh T, Kerneis M, Combes A, Camici PG, de Lemos JA, Metra M. Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute Myocarditis. Circulation 2022; 145:1123-1139. [PMID: 35404682 PMCID: PMC8989611 DOI: 10.1161/circulationaha.121.056817] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19–associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. Methods: A total of 112 patients with suspected AM from 56 963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19–associated AM. Results: AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19–associated pneumonia. Twenty-one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47; P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). Conclusions: AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.)
| | - Laura Lupi
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., M.D.P., M. Metra)
| | - Matteo Palazzini
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.)
| | - Nicholas S Hendren
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.L.G., J.A.d.L.)
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.L.G., J.A.d.L.)
| | - Carlo V Cannistraci
- Center for Complex Network Intelligence, Tsinghua Laboratory of Brain and Intelligence, Department of Computer Science, Department of Biomedical Engineering, Tsinghua University, Beijing, China (C.V.C.).,Center for Systems Biology Dresden, Germany (C.V.C.)
| | - Matthieu Schmidt
- Sorbonne Université, UMRS 1166, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, France (M. Schmidt, G.H., A. Combes)
| | - Guillaume Hekimian
- Sorbonne Université, UMRS 1166, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, France (M. Schmidt, G.H., A. Combes)
| | - Giovanni Peretto
- San Raffaele Hospital and Vita Salute University, Milano, Italy (G.P., S.S., P.G.C.)
| | - Thomas Bochaton
- Urgences et Soins Critiques Cardiologiques, Hôpital Cardiologique, Hospices Civils de Lyon, Bron, France (T.B., A.H.)
| | - Ahmad Hayek
- Urgences et Soins Critiques Cardiologiques, Hôpital Cardiologique, Hospices Civils de Lyon, Bron, France (T.B., A.H.)
| | - Nicolas Piriou
- Université Nantes, CHU Nantes, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, l'Institut du Thorax, France (N.P.)
| | - Sergio Leonardi
- University of Pavia and Fondazione Istituto di Ricovero e Cura a Carattere Scientificio Policlinico S. Matteo, Italy (S.L., S.G., A.T.)
| | - Stefania Guida
- University of Pavia and Fondazione Istituto di Ricovero e Cura a Carattere Scientificio Policlinico S. Matteo, Italy (S.L., S.G., A.T.)
| | - Annalisa Turco
- University of Pavia and Fondazione Istituto di Ricovero e Cura a Carattere Scientificio Policlinico S. Matteo, Italy (S.L., S.G., A.T.)
| | - Simone Sala
- San Raffaele Hospital and Vita Salute University, Milano, Italy (G.P., S.S., P.G.C.)
| | - Aitor Uribarri
- Departamento de Cardiología, Hospital Clínico Universitario, Valladolid, Spain (A.U.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain (A.U.)
| | - Caroline M Van de Heyning
- Department of Cardiology, Antwerp University Hospital, and Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton Research Group, Antwerp University, Belgium (C.M.V.d.H.)
| | - Massimo Mapelli
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientificio, Milano, Italy (M. Mapelli, J.C., P.A.).,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M. Mapelli, J.C., P.A.)
| | - Jeness Campodonico
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientificio, Milano, Italy (M. Mapelli, J.C., P.A.).,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M. Mapelli, J.C., P.A.)
| | - Patrizia Pedrotti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.)
| | - Maria Isabel Barrionuevo Sánchez
- Cardiology Department, Bellvitge University Hospital, Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, L'Hospotalet del Llobregat, Barcelona, Spain (M.I.B.S., A.A.S.)
| | - Albert Ariza Sole
- Cardiology Department, Bellvitge University Hospital, Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, L'Hospotalet del Llobregat, Barcelona, Spain (M.I.B.S., A.A.S.)
| | - Marco Marini
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I-GM Lancisi-G Salesi, Ancona, Italy (M. Marini, M.V.M.)
| | - Maria Vittoria Matassini
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I-GM Lancisi-G Salesi, Ancona, Italy (M. Marini, M.V.M.)
| | - Mickael Vourc'h
- Department of Anesthesiology and Surgical Intensive Care, Hôpital Laennec, University Hospital of Nantes, France (M.V.).,School of Medicine, UPRES EA 3826, Thérapeutiques Cliniques et Expérimentales des Infections, IRS2 Nantes Biotech, France (M.V.)
| | - Antonio Cannatà
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, United Kingdom (A. Cannatà, D.I.B., T.M.).,Department of Cardiology, King's College Hospital London, United Kingdom (A. Cannatà, D.I.B., T.M.)
| | - Daniel I Bromage
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, United Kingdom (A. Cannatà, D.I.B., T.M.).,Department of Cardiology, King's College Hospital London, United Kingdom (A. Cannatà, D.I.B., T.M.)
| | | | - Jorge Salamanca
- Cardiology Department, Hospital Universitario De La Princesa, Madrid, Spain (J.S., P.D.-V.)
| | - Pablo Diez-Villanueva
- Cardiology Department, Hospital Universitario De La Princesa, Madrid, Spain (J.S., P.D.-V.)
| | - Jukka Lehtonen
- Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, Finland (J.L.)
| | - Florent Huang
- Service de Cardiologie, Hôpital Foch, Suresnes, France (F.H., S. Russel)
| | - Stéphanie Russel
- Service de Cardiologie, Hôpital Foch, Suresnes, France (F.H., S. Russel)
| | - Francesco Soriano
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.)
| | | | - Manlio Cipriani
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.)
| | - Manuela Bramerio
- Department of Histopathology, Niguarda Hospital, Milano, Italy (M.B.)
| | - Mattia Di Pasquale
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., M.D.P., M. Metra)
| | - Aurelia Grosu
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A.G., M. Senni)
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A.G., M. Senni)
| | - Davide Farina
- Institute of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (D.F.)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientificio, Milano, Italy (M. Mapelli, J.C., P.A.).,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M. Mapelli, J.C., P.A.)
| | - Stefania Rizzo
- Cardiovascular Pathology Unit, Azienda Ospedaliera, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (S. Rizzo, M.D.G., C.B.)
| | - Monica De Gaspari
- Cardiovascular Pathology Unit, Azienda Ospedaliera, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (S. Rizzo, M.D.G., C.B.)
| | - Francesca Marzo
- Department of Cardiology, Infermi Hospital, Rimini, Italy (F.M.)
| | - Jason M Duran
- Division of Cardiology, Department of Medicine, University of California San Diego (J.M.D., E.D.A.)
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego (J.M.D., E.D.A.)
| | - Cristina Giannattasio
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.P., P.P. F.S., M.C., C.G.).,Department of Health Sciences, University of Milano-Bicocca, Monza, Italy (C.G.)
| | - Cristina Basso
- Cardiovascular Pathology Unit, Azienda Ospedaliera, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (S. Rizzo, M.D.G., C.B.)
| | - Theresa McDonagh
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, United Kingdom (A. Cannatà, D.I.B., T.M.).,Department of Cardiology, King's College Hospital London, United Kingdom (A. Cannatà, D.I.B., T.M.)
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Institut National de la Santé et de la Recherche Médicale UMRS1166, Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (M.K.)
| | - Alain Combes
- Sorbonne Université, UMRS 1166, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, France (M. Schmidt, G.H., A. Combes)
| | - Paolo G Camici
- San Raffaele Hospital and Vita Salute University, Milano, Italy (G.P., S.S., P.G.C.)
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.L.G., J.A.d.L.)
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., M.D.P., M. Metra)
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11
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Power JR, Keyt LK, Adler ED. Myocarditis following COVID-19 vaccination: incidence, mechanisms, and clinical considerations. Expert Rev Cardiovasc Ther 2022; 20:241-251. [PMID: 35414326 PMCID: PMC9115793 DOI: 10.1080/14779072.2022.2066522] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Vaccines have demonstrated protection against the morbidity and mortality of COVID-19, but concerns regarding the rare side effect of acute myocarditis have stymied immunization efforts. This review aims to describe the incidence and theorized mechanisms of COVID vaccine-associated myocarditis and review relevant principles for management of vaccine-associated myocarditis. AREAS COVERED Epidemiologic studies of myocarditis after COVID vaccination are reviewed, which show an incidence of approximately 20-30 per million patients. The vast majority of these cases are seen with mRNA vaccines especially in male patients under 30 years of age. Mechanisms are largely theoretical, but molecular mimicry and dysregulated innate immune reactions have been proposed. While studies suggest that this subtype of myocarditis is mild and self-limited, long-term evidence is lacking. Principles of myocarditis treatment and surveillance are outlined as they apply to COVID vaccine-associated myocarditis. EXPERT OPINION COVID vaccine-associated myocarditis is rare but well described in certain at-risk groups. Better understanding of its pathogenesis is key to mitigating this complication and advancing vaccination efforts. Risk-benefit analyses demonstrate that individual- and population-level benefits of vaccination exceed the risks of this rare and mild form of myocarditis.
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Affiliation(s)
- John R. Power
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
| | - Lucas K. Keyt
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
| | - Eric D. Adler
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
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12
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Ammirati E, Bizzi E, Veronese G, Groh M, Van de Heyning CM, Lehtonen J, Pineton de Chambrun M, Cereda A, Picchi C, Trotta L, Moslehi JJ, Brucato A. Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis. Front Med (Lausanne) 2022; 9:838564. [PMID: 35350578 PMCID: PMC8958011 DOI: 10.3389/fmed.2022.838564] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy
| | - Emanuele Bizzi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Giacomo Veronese
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndromes, CEREO, Suresnes, France
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Caroline M. Van de Heyning
- Department of Cardiology, Antwerp University Hospital, and GENCOR Research Group, Antwerp University, Antwerp, Belgium
| | - Jukka Lehtonen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, APHP, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence National Lupus et SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, ICAN, Paris, France
| | - Alberto Cereda
- Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy
| | - Chiara Picchi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Lucia Trotta
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Javid J. Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco, ” Fatebenefratelli Hospital, University of Milano, Milano, Italy
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13
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Abstract
Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe hemodynamic compromise secondary to acute myocardial inflammation, often presenting as profound cardiogenic shock, life-threatening ventricular arrhythmias and/or electrical storm. FM may be refractory to conventional therapies and require mechanical circulatory support (MCS). The immune system has been recognized as playing a pivotal role in the pathophysiology of myocarditis, leading to an increased focus on immunosuppressive treatment strategies. Recent data have highlighted not only the fact that FM has significantly worse outcomes than non-FM, but that prognosis and management strategies of FM are heavily dependent on histological subtype, placing greater emphasis on the role of endomyocardial biopsy in diagnosis. The impact of subtype on severity and prognosis will likewise influence how aggressively the myocarditis is managed, including whether MCS is warranted. Many patients with refractory cardiogenic shock secondary to FM end up requiring MCS, with venoarterial extracorporeal membrane oxygenation demonstrating favorable survival rates, particularly when initiated prior to the development of multiorgan failure. Among the challenges facing the field are the need to more precisely identify immunopathophysiological pathways in order to develop targeted therapies, and the need to better optimize the timing and management of MCS to minimize complications and maximize outcomes.
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14
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Ammirati E, Varrenti M, Veronese G, Fanti D, Nava A, Cipriani M, Pedrotti P, Garascia A, Bottiroli M, Oliva F, Bramerio M, Veronese S, Giannattasio C, Bonoldi E, Perno CF, Camici PG, Frigerio M. Prevalence and outcome of patients with acute myocarditis and positive viral search on nasopharyngeal swab. Eur J Heart Fail 2021; 23:1242-1245. [PMID: 34036693 DOI: 10.1002/ejhf.2247] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/06/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - Marisa Varrenti
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy.,Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Veronese
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy.,Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Diana Fanti
- Chemical-Clinical and Microbiological Analyses, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alice Nava
- Chemical-Clinical and Microbiological Analyses, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | | | | | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy
| | | | | | - Cristina Giannattasio
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy.,Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | | | - Carlo F Perno
- Chemical-Clinical and Microbiological Analyses, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo G Camici
- IRCCS San Raffaele Hospital and Vita Salute University, Milano, Italy
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy
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15
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Smith V, Devane D, Nichol A, Roche D. Care bundles for improving outcomes in patients with COVID-19 or related conditions in intensive care - a rapid scoping review. Cochrane Database Syst Rev 2020; 12:CD013819. [PMID: 33348427 PMCID: PMC8078496 DOI: 10.1002/14651858.cd013819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the strain of coronavirus that causes coronavirus disease 2019 (COVID-19) can cause serious illness in some people resulting in admission to intensive care units (ICU) and frequently, ventilatory support for acute respiratory failure. Evaluating ICU care, and what is effective in improving outcomes for these patients is critical. Care bundles, a small set of evidence-based interventions, delivered together consistently, may improve patient outcomes. To identify the extent of the available evidence on the use of care bundles in patients with COVID-19 in the ICU, the World Health Organization (WHO) commissioned a scoping review to inform WHO guideline discussions. This review does not assess the effectiveness of the findings, assess risk of bias, or assess the certainty of the evidence (GRADE). As this review was commissioned to inform guideline discussions, it was done rapidly over a three-week period from 26 October to 18 November 2020. OBJECTIVES To identify and describe the available evidence on the use of care bundles in the ICU for patients with COVID-19 or related conditions (acute respiratory distress syndrome (ARDS) viral pneumonia or pneumonitis), or both. In carrying out the review the focus was on characterising the evidence base and not evaluating the effectiveness or safety of the care bundles or their component parts. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Library (CENTRAL and the Cochrane COVID-19 Study Register) and the WHO International Clinical Trials Registry Platform on 26 October 2020. SELECTION CRITERIA Studies of all designs that reported on patients who are critically ill with COVID-19, ARDS, viral pneumonia or pneumonitis, in the ICU setting, where a care bundle was implemented in providing care, were eligible for inclusion. One review author (VS) screened all records on title and abstract. A second review author (DR) checked 20% of excluded and included records; agreement was 99.4% and 100% respectively on exclude/include decisions. Two review authors (VS and DR) independently screened all records at full-text level. VS and DR resolved any disagreements through discussion and consensus, or referral to a third review author (AN) as required. DATA COLLECTION AND ANALYSIS One review author (VS) extracted the data and a second review author (DR) checked 20% of this for accuracy. As the review was not designed to synthesise effectiveness data, assess risk of bias, or characterise the certainty of the evidence (GRADE), we mapped the extracted data and presented them in tabular format based on the patient condition; that is patients with confirmed or suspected COVID-19, patients with ARDS, patients with any influenza or viral pneumonia, patients with severe respiratory failure, and patients with mixed conditions. We have also provided a narrative summary of the findings from the included studies. MAIN RESULTS We included 21 studies and identified three ongoing studies. The studies were of variable designs and included a systematic review of standardised approaches to caring for critically ill patients in ICU, including but not exclusive to care bundles (1 study), a randomised trial (1 study), prospective and retrospective cohort studies (4 studies), before and after studies (7 studies), observational quality improvement reports (4 studies), case series/case reports (3 studies) and audit (1 study). The studies were conducted in eight countries, most commonly China (5 studies) and the USA (4 studies), were published between 1999 and 2020, and involved over 2000 participants in total. Studies categorised participant conditions patients with confirmed or suspected COVID-19 (7 studies), patients with ARDS (7 studies), patients with another influenza or viral pneumonia (5 studies), patients with severe respiratory failure (1 study), and patients with mixed conditions (1 study). The care bundles described in the studies involved multiple diverse practices. Guidance on ventilator settings (10 studies), restrictive fluid management (8 studies), sedation (7 studies) and prone positioning (7 studies) were identified most frequently, while only one study mentioned chest X-ray. None of the included studies reported the prespecified outcomes ICU-acquired weakness (muscle wasting, weight loss) and users' experience adapting care bundles. Of the remaining prespecified outcomes, 14 studies reported death in ICU, nine reported days of ventilation (or ventilator-free days), nine reported length of stay in ICU in days, five reported death in hospital, three reported length of stay in hospital in days, and three reported adherence to the bundle. AUTHORS' CONCLUSIONS This scoping review has identified 21 studies on care bundle use in critically ill patients in ICU with COVID-19, ARDS, viral influenza or pneumonia and severe respiratory failure. The data for patients with COVID-19 specifically are limited, derived mainly from observational quality improvement or clinical experiential accounts. Research is required, urgently, to further assess care bundle use and optimal components of these bundles in this patient cohort. The care bundles described were also varied, with guidance on ventilator settings described in 10 care bundles, while chest X-ray was part mentioned in one care bundle in one study only. None of the studies identified in this scoping review measured users' experience of adapting care bundles. Optimising care bundle implementation requires that the components of the care bundle are collectively and consistently applied. Data on challenges, barriers and facilitators to implementation are needed. A formal synthesis of the outcome data presented in this review and a critical appraisal of the evidence is required by a subsequent effectiveness review. This subsequent review should further explore effect estimates across the included studies.
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
- HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, Galway, Ireland
| | - Alistair Nichol
- University College Dublin, Dublin, Ireland
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia and The Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
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16
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Good or bad: Application of RAAS inhibitors in COVID-19 patients with cardiovascular comorbidities. Pharmacol Ther 2020; 215:107628. [PMID: 32653530 PMCID: PMC7346797 DOI: 10.1016/j.pharmthera.2020.107628] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/06/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a newly emerged coronavirus (CoV) called Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). COVID-19 patients with cardiovascular disease (CVD) comorbidities have significantly increased morbidity and mortality. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor type 1 blockers (ARBs) improve CVD outcomes; however, there is concern that they may worsen the prognosis of CVD patients that become infected with SARS-CoV-2 because the virus uses the ACE2 receptor to bind to and subsequently infect host cells. Thus, some health care providers and media sources have questioned the continued use of ACE inhibitors and ARBs. In this brief review, we discuss the effect of ACE inhibitor-induced bradykinin on the cardiovascular system, on the renin-angiotensin-aldosterone system (RAAS) regulation in COVID-19 patients, and analyze recent clinical studies regarding patients treated with RAAS inhibitors. We propose that the application of RAAS inhibitors for COVID-19 patients with CVDs may be beneficial rather than harmful.
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17
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Ammirati E, Frigerio M, Adler ED, Basso C, Birnie DH, Brambatti M, Friedrich MG, Klingel K, Lehtonen J, Moslehi JJ, Pedrotti P, Rimoldi OE, Schultheiss HP, Tschöpe C, Cooper LT, Camici PG. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document. Circ Heart Fail 2020; 13:e007405. [PMID: 33176455 PMCID: PMC7673642 DOI: 10.1161/circheartfailure.120.007405] [Citation(s) in RCA: 326] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | - Maria Frigerio
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | - Eric D. Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla (E.D.A., M.B.)
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy (C.B.)
| | - David H. Birnie
- University of Ottawa Heart Institute, Ontario, Canada (D.H.B.)
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla (E.D.A., M.B.)
- IONIS Pharmaceuticals, Carlsbad, CA (M.B.)
| | - Matthias G. Friedrich
- Department of Medicine and Diagnostic Radiology, McGill University, Montreal, Quebec, Canada (M.G.F.)
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Germany (K.K.)
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital, Finland (J.L.)
| | - Javid J. Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.J.M.)
| | - Patrizia Pedrotti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy (E.A., M.F., P.P.)
| | | | | | - Carsten Tschöpe
- Institute of Health Center for Regenerative Therapies (BCRT), Charité, University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany (C.T.)
- Department of Cardiology, Charité–University Medicine Berlin, Campus Virchow Klinikum, Germany (C.T.)
| | - Leslie T. Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Paolo G. Camici
- Vita Salute University and San Raffaele Hospital, Milano, Italy (P.G.C.)
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Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis. Int J Cardiol 2020; 324:131-138. [PMID: 33122017 DOI: 10.1016/j.ijcard.2020.10.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 01/19/2023]
Abstract
Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.
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19
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Tersalvi G, Veronese G, Winterton D. Emerging evidence of myocardial injury in COVID-19: A path through the smoke. Theranostics 2020; 10:9888-9889. [PMID: 32863965 PMCID: PMC7449910 DOI: 10.7150/thno.50788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 01/19/2023] Open
Abstract
Although Coronavirus Disease 2019 (COVID-19) presents primarily as a respiratory condition, a growing body of evidence shows it is a systemic disease. Recently, many authors have described myocardial damage in COVID-19, suggesting various pathophysiological mechanisms. In this issue, Cao et al. demonstrate the prognostic value of cardiac troponin I in patients with COVID-19, showing how even minor elevations in this molecule carry a great impact on patient mortality. In a situation such as the worldwide COVID-19 pandemic, where healthcare resources are placed under enormous stress, readily available tests such as this play an important role in helping clinicians identify patients at greater risk of developing severe forms of the disease, and should be included in the initial triage panel.
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Affiliation(s)
- Gregorio Tersalvi
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
- Department of Internal Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Giacomo Veronese
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
- School of Medicine, University of Milan-Bicocca, Milan, Italy
| | - Dario Winterton
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
- School of Medicine, University of Milan-Bicocca, Milan, Italy
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