Influence of echocardiographic measurements and renal impairments on the prognosis of fulminant myocarditis

PD-1 inhibitors-associated myocarditis in non-small cell lung cancer patients

Background

Immune checkpoint inhibitors (ICIs)-associated myocarditis remains a rare but fatal adverse event. The authors sought to provide a comprehensive clinical description of ICI-associated myocarditis by analyzing symptoms, laboratory indicators, imaging features, and management of ICI-associated myocarditis in patients with non-small cell lung cancer (NSCLC).

Methods

A retrospective study was conducted to analyze 14 ICI-associated myocarditis cases and 45 control patients to clarify clinical features of ICI-associated myocarditis. Detailed laboratory tests and imaging examinations were performed in 14 cases, and the rescue process and follow-up after the onset of myocarditis were recorded.

Results

A total of 14 (2.08%) NSCLC patients developed ICI-related myocarditis, with a median time of onset of 34 days (interquartile range, 12 to 146 days) after ICI initiation. The most common concurrent adverse events in cases were myositis (P<0.001) and peripheral neuritis (P<0.001). Among cases, cardiac troponin I (cTnI) levels were abnormally elevated in 92% of patients, and electrocardiogram (ECG) showed abnormal in all cases. Steroid therapy was used in 92.9% of patients with ICI-associated myocarditis, of which the response rate to steroids was 76.9% and the mortality rate was 7.1%. A dose of 1 g/d of glucocorticoid supplemented by immunoglobulin was observed to be effective for severe myocarditis.

Conclusions

Early identification and treatment are essential for managing myocarditis caused by ICI. Routine monitoring of cTnI level and ECG is most sensitive for the early diagnosis of ICI-related myocarditis. High-dose of glucocorticoids can effectively relieve the symptoms of ICI-associated myocarditis and stabilize the condition, especially for fulminant myocarditis.

Low T3 syndrome is associated with 30-day mortality in adult patients with fulminant myocarditis

Background

Fulminant myocarditis (FM) is a critical disease with high early mortality. Low triiodothyronine syndrome (LT3S) was a strong predictor of poor prognosis of critical diseases. This study investigated whether LT3S was associated with 30-day mortality in FM patients.

Methods

Ninety-six FM patients were divided into LT3S (n=39, 40%) and normal free triiodothyronine (FT3) (n=57, 60%) groups based on serum FT3 level. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. Kaplan-Meier curve was used to compare 30-day mortality between two groups. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to assess the value of FT3 level for 30-day mortality prediction.

Results

Compared to normal FT3 group, LT3S group had higher incidence of ventricular arrhythmias, worse hemodynamics, worse cardiac function, more severe kidney impairment, and higher 30-day mortality (48.7% vs. 12.3%, P<0.001). In univariable analysis, LT3S (odds ratio [OR]:6.786, 95% confidence interval [CI]:2.472-18.629, P<0.001) and serum FT3 (OR:0.272, 95%CI:0.139-0.532, P<0.001) were significant strong predictors of 30-day mortality. After adjustment for confounders in multivariable analysis, LT3S (OR:3.409, 95%CI:1.019-11.413, P=0.047) and serum FT3 (OR:0.408, 95%CI:0.199-0.837, P=0.014) remained independent 30-day mortality predictors. The area under the ROC curve of FT3 level was 0.774 (cut-off: 3.58, sensitivity: 88.46%, specificity: 62.86%). In DCA, FT3 level showed good clinical-application value for 30-day mortality prediction.

Conclusion

In FM patients, LT3S could independently predict 30-day mortality. FT3 level was a strong 30-day mortality predictor and a potentially useful risk-stratification biomarker.

Influence of confirmed viral infection on adult acute fulminant myocarditis supported with extracorporeal membrane oxygenation

BACKGROUND

The impact of etiologies of acute fulminant myocarditis (AFM), which requires extracorporeal membrane oxygenation (ECMO), on clinical outcomes remains unknown. This study aimed to investigate the risk factors for ECMO weaning and mortality among patients with AFM due to viral etiologies in a tertiary referral medical center.

METHODS

We included 33 adults with AFM who received ECMO and were admitted between January 2002 and January 2021. General demographics, laboratory data, echocardiography findings, and long-term outcomes were analyzed for confirmed viral etiology and unconfirmed etiology groups.

RESULTS

The overall hospital survival rate was 54.5%. The age, sex, severity of the hemodynamic condition, and cardiac rhythm were similar between the two groups. Multivariate Cox regression analysis revealed that a confirmed viral etiology (HR 4.201, 95% CI 1.061-16.666), peri-ECMO renal replacement therapy (RRT) (HR 9.804, 1.140-83.333) and a high positive end-expiratory pressure (PEEP) in the ventilator settings at 24 h after ECMO (HR 1.479, 1.020-2.143) were significant prognostic factors for in-hospital mortality. Peri-ECMO RRT was also a significant negative prognostic factor for successful ECMO weaning (OR 0.061, 0.006-0.600) in the multivariate logistic model.

CONCLUSIONS

Among AFM patients receiving ECMO support, RRT use was associated with a decreased chance of survival to ECMO weaning. Multiple organ dysfunction and a high PEEP were also predictive of a lower chance of hospital survival. Those with a confirmed diagnosis of viral myocarditis may require more medical attention due to the higher risk of hospital mortality than those without a definite diagnosis.

Myoglobin and left ventricular ejection fraction as predictive markers for death in children with fulminant myocarditis

BACKGROUND

Fulminant myocarditis (FM) is an inflammatory process of the myocardium and an important cause of cardiac dysfunction in children; it is characterized by rapid onset, acute progression, and high mortality. The study sought to describe the clinical characteristics and prognostic factors in children with FM.

METHODS

The study population consists of 37 consecutive patients admitted from May 2014 to December 2021 with a diagnosis of FM. According to the prognosis of children with FM during hospitalization, they were divided into "survival" group (25 cases) and "death" group (12 cases). A multivariate logistic regression analysis was performed to identify the independent predictors of in-hospital mortality in the patients, and receiver operating characteristic (ROC) curve was used to explore the predictive value of related factors.

RESULTS

The 37 children with FM had an average age of 8.35 ± 4.36 years old. Twenty-five of the patients survived and 12 died. Twenty-five of the children were discharged from the hospital after a series of active rescue treatments such as nutritional myocardial drugs, high-dose intravenous immunoglobulin (IVIG), glucocorticoids (GCs), temporary pacemaker (TP), extracorporeal membrane oxygenation (ECMO), and continuous renal replacement therapy (CRRT).Twelve of the children were classified into the death group because the resuscitation failed. The levels of procalcitonin (PCT), creatine kinase (CK), and myoglobin (MYO) in the death group were all higher than in the survival group (all P < 0.05), and the left ventricular ejection fraction (LVEF) in the death group was significantly lower than in the survival group (P = 0.002). The binary logistic regression analysis revealed that MYO [OR:1.006; 95%CI:(1-1.012); P = 0.045] and LVEF [OR: 0.876; 95% CI: (0.785-0.978); P = 0.019] were independent predictors of FM. ROC curve analysis showed that the area under ROC curve (AUC) of MYO and LVEF was [AUC:0.957; 95%CI:0.897~1] and [AUC:0.836; 95%CI:0.668~1], and the area under the combined ROC curve for MYO + LVEF was significantly higher than that for MYO or LVEF alone (P < 0.05), indicating that the MYO + LVEF combined diagnosis had a higher predictive value for FM.

CONCLUSION

The levels of MYO and LVEF can be markers for prognosis of FM and can effectively evaluate the disease severity. Their combination can improve forecast accuracy; thus, the detection of the above-mentioned indexes possesses a higher value for clinical applications.

Diagnosis, treatment and predictors of prognosis of myocarditis. A narrative review

Although it has been recognized for almost two centuries, myocarditis is still a challenging diagnosis due to the wide heterogeneity of its clinical manifestations and evolution. Moreover, the diagnostic gold standard, endomyocardial biopsy (EMB), is infrequently used, making hard to determine the exact incidence of myocarditis. Clinical presentation includes a wide range of symptoms, ranging from asymptomatic or subclinical disease with mild dyspnea and chest pain to sudden death, due to cardiogenic shock or malignant ventricular arrhythmias. Equally, the evolution of myocarditis largely varies: albeit short-term prognosis is usually good, with complete or partial recovery, dilated cardiomyopathy with chronic heart failure is the major long-term consequence of myocarditis, developing often several years after the acute onset. This narrative review aims to summarize the current knowledge about myocarditis, with a particular attention to predictors of short- and long-term prognosis, in order to provide a rational and practical approach to the diagnosis, evaluation and treatment of suspected myocarditis.

Establishment and assessment of a nomogram model for predicting the risk of fulminant myocarditis: A STROBE compliant cross-sectional study

ABSTRACT

We aimed to identify potential clinical predictors associated with the risk of fulminant myocarditis, and further to establish and assess a nomogram model based on significant attributes for clinical practicability.This is a retrospective, cross-sectional study, involving 28 patients with fulminant myocarditis and 35 age-, and sex-matched patients with non-fulminant myocarditis. Effect-size estimates are expressed as odds ratio (OR) and 95% confidence interval (CI).Fifteen factors were primarily identified to be associated with the significant risk of fulminant myocarditis after adjusting for confounders. Due to strong correlation, 6 factors were retained, including mean arterial pressure (OR, 95% CI, P: .82, .72-.94, .005), creatinine (2.15, 1.13-4.10, 0.020), blood urea nitrogen (1.45, 1.04-2.02, 0.028), aspartate aminotransferase (2.62, 1.16-5.91, 0.021), troponin I (1.43, 1.07-1.90, 0.015), and ventricular wall motion abnormality (25.81, 2.52-264.69, 0.006). The contribution of the 6 significant factors to predicting fulminant myocarditis risk was significant from multi-angle analyses, and regressing these factors in a nomogram model exhibited good predictive accuracy, as reflected by both C-index (>90%, P < .001).We have identified 6 clinical factors in significant association with fulminant myocarditis, and their prediction capability was more obvious in a nomogram model. Further investigations with larger sample sizes and longer follow-up intervals are warranted.

Predictive Value of the Age, Creatinine, and Ejection Fraction (ACEF) Score in Patients With Acute Fulminant Myocarditis

Objective

Patients with acute fulminant myocarditis often have more adverse cardiovascular events and higher mortality. The purpose of this study was to evaluate the usefulness of age, creatinine, and left ventricular ejection fraction (ACEF score), in determining the risk that acute fulminant myocarditis will lead to serious cardiovascular events, death, and cardiac dysfunction.

Methods

We retrospectively reviewed the demographics, laboratory tests, medications, echocardiographic examinations, in-hospital clinical outcomes, major adverse cardiovascular events (MACE), and survival rate at 1 year in the medical records of 220 consecutive subjects suffering from acute fulminant myocarditis from January 2013 to June 2019.

Results

Two hundred twenty patients were divided into a survivor group and a non-survivor group. This study found that patients in the non-survivor group were older, had higher heart rates, and had more serious injuries to multiple organ functions. A high ACEF score at admission was independently associated with an unfavorable prognosis, and it was a predictor of in-hospital mortality. The current analysis extends the predictive performance of the ACEF scores at 30 days by evaluating echocardiographic data as applied to survivors of fulminant myocarditis and cumulative rates of MACE at 1 year. The results indicated that patients with high ACEF scores had poor recovery of cardiac function, and higher rates of MACE, all-cause death, and heart failure at 1 year than the low-ACEF group.

Conclusion

The ACEF score was identified as an effective predictor of poor in-hospital outcomes, worse cardiac recovery after 30 days, and higher rates of MACE, all-cause death, and heart failure at 1 year in patients who had acute fulminant myocarditis. These data suggest that its predictive accuracy means the ACEF score could be used to assess the prognosis of patients with acute fulminant myocarditis.

Risk factors analysis of prognosis of adult acute severe myocarditis

BACKGROUND

Adult severe myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock with a high hospital mortality rate.

AIM

To analyze the risk factors affecting the short-term prognosis of adult acute severe myocarditis (ASM).

METHODS

Adult patients with ASM (ASM group, n = 218) and acute nonsevere myocarditis (ANSM group, n = 80) who came to our department from January 2014 to January 2020 were enrolled in this study. Patients with ASM were divided into the ASM survival group (n = 185) and ASM nonsurvival group (n = 33) according to the treatment results during hospitalization. The clinical symptoms, laboratory examinations, treatment methods, complications, and the relationship between the treatment results of the two groups were retrospectively compared and discussed. The risk factors for death in patients with severe myocarditis were analyzed by binary logistic regression. A follow-up to 5.5 years was conducted on patients in the ASM survival group and ANSM group after discharge, and the readmission rate and incidence rate of dilated cardiomyopathy were analyzed.

RESULTS

Compared with the ASM survival group, the ASM nonsurvival group had longer QRS complex, higher incidence of cardiogenic shock, higher serum creatinine (SCr, 235μmol/L vs 89 μmol/L, P < 0.05), higher sensitive cardiac troponin I (cTnI, 4.45 μg/L vs 1.66 μg/L, P < 0.05) and brain natriuretic peptide (BNP, 1756 pg/mL vs 401 pg/mL, P < 0.05). The binary logistic regression revealed that there were statistical differences between the two groups in SCr, cTnI, and BNP values (all P < 0.05). After discharging from the hospital, patients in the ASM group and ANSM group had no significant differences in the readmission rate and incidence rate of dilated cardiomyopathy.

CONCLUSION

Elevated SCr, cTnI, and BNP are independent predictors for poor prognosis in patients with ASM. The long-term prognosis of patients in the ASM survival group is good.

Effect of Acute Immunosuppression on Left Ventricular Recovery and Mortality in Fulminant Viral Myocarditis: A Case Series and Review of Literature

Background

Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies.

Methods

We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM.

Results

We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery.

Conclusions

Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.