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Kawano H, Ikeda S, Kanaoka K, Sato S, Eto R, Ueno Y, Onoue K, Saito Y, Maemura K. Multisystemic Inflammation Influences Prognosis in Fulminant Lymphocytic Myocarditis. Circ J 2024; 88:722-731. [PMID: 38432947 DOI: 10.1253/circj.cj-23-0914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
BACKGROUND Multisystem inflammatory syndrome (MIS) is a hyperinflammatory shock associated with cardiac dysfunction and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, there are no reports on using MIS criteria, such as multisystemic inflammation (MSI) in fulminant myocarditis, without SARS-CoV-2 infection. This study investigated the differences in clinical characteristics and course between patients with fulminant lymphocytic myocarditis (FLM) plus MSI and those without MSI.Methods and Results: This multicenter retrospective cohort study included 273 patients with FLM registered in the JROAD-DPC database between April 2014 and March 2017. We evaluated the presence of MSI using criteria modified from previously reported MIS criteria and compared the characteristics and risk of mortality or heart transplantation between FLM patients with MSI and without MSI. Of the 273 patients with FLM, 107 (39%) were diagnosed with MSI. The MSI group was younger (44 vs. 57 years; P<0.0001) and had more females (50% vs. 36%; P=0.0236), a higher incidence of pericardial effusion (58% vs. 40%; P=0.0073), and a lower 90-day mortality rate (19% vs. 33%; P=0.0185) than the non-MSI group. The risk of mortality at 90 days was lower in FLM patients aged <50 years with MSI aged <50 years than in those without MSI (P=0.0463). CONCLUSIONS These results suggest that MSI may influence the prognosis of FLM, especially in patients aged <50 years.
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Affiliation(s)
- Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Koshiro Kanaoka
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
- Department of Cardiovascular Medicine, Nara Medical University
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital
| | - Ryo Eto
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Yuki Ueno
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University
- Nara Prefecture Seiwa Medical Center
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
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2
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Bernhard B, Joss P, Greisser N, Stark AW, Schütze J, Shiri I, Safarkhanlo Y, Fischer K, Guensch DP, Bastiaansen JAM, Pavlicek M, Benz DC, Kwong RY, Gräni C. Prognostic value of visual and quantitative CMR regional myocardial function in patients with suspected myocarditis. Int J Cardiovasc Imaging 2024; 40:907-920. [PMID: 38427272 PMCID: PMC11052711 DOI: 10.1007/s10554-024-03059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/17/2024] [Indexed: 03/02/2024]
Abstract
According to updated Lake-Louise Criteria, impaired regional myocardial function serves as a supportive criterion in diagnosing myocarditis. This study aimed to assess visual regional wall motional abnormalities (RWMA) and novel quantitative regional longitudinal peak strain (RLS) for risk stratification in the clinical setting of myocarditis. In patients undergoing CMR and meeting clinical criteria for suspected myocarditis global longitudinal strain (GLS), late gadolinium enhancement (LGE), RWMA and RLS were assessed in the anterior, septal, inferior, and lateral regions and correlated to the occurrence of major adverse cardiac events (MACE), including heart failure hospitalization, sustained ventricular tachycardia, recurrent myocarditis, and all-cause death. In 690 consecutive patients (age: 48.0 ± 16.0 years; 37.7% female) with suspected myocarditis impaired RLS was correlated with RWMA and LV-GLS but not with the presence of LGE. At median follow up of 3.8 years, MACE occurred in 116 (16.8%) patients. Both, RWMA and RLS in anterior-, septal-, inferior-, and lateral- locations were univariately associated with outcomes (all p < 0.001), but not after adjusting for clinical characteristics and LV-GLS. In the subgroup of patients with normal LV function, RWMA were not predictive of outcomes, whereas septal RLS had incremental and independent prognostic value over clinical characteristics (HRadjusted = 1.132, 95% CI 1.020-1.256; p = 0.020). RWMA and RLS can be used to assess regional impairment of myocardial function in myocarditis but are of limited prognostic value in the overall population. However, in the subgroup of patients with normal LV function, septal RLS represents a distinctive marker of regional LV dysfunction, offering potential for risk-stratification.
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Affiliation(s)
- Benedikt Bernhard
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philippe Joss
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noah Greisser
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan Schütze
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasaman Safarkhanlo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kady Fischer
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dominik P Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jessica A M Bastiaansen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Translation Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Maryam Pavlicek
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Cardiology, University Hospital Bern, Freiburgstrasse, CH - 3010, Bern, Switzerland.
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3
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Müller SH, Holzner PA, Loop T. [Asymptomatic SARS-CoV-2 Infection and "in situ split" Liver Resection with Fatal Outcome - A Case Report]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:660-664. [PMID: 38056445 DOI: 10.1055/a-2141-4052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
We report the perioperative course of a 47-year-old patient who underwent a two-stage liver resection for bilobar metastatic colorectal carcinoma. The respiratory asymptomatic patient was tested positive for SARS-CoV-2 by PCR detection one day before the second surgical procedure. Postoperatively, the patient suffered cardiovascular arrest on postoperative day 8 and died despite immediately initiated resuscitative measures. With an initial clinical suspicion of vascular liver failure, postmortem pathologic examination revealed the underlying cause of death to be COVID-19-related myocarditis with acute right heart failure. Individual multidisciplinary risk assessment should be considered very critically when deviating from the "7-week rule" because the benefit is difficult to objectify, even in oncologic patients.
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4
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Axelrod ML, Meijers WC, Screever EM, Qin J, Carroll MG, Sun X, Tannous E, Zhang Y, Sugiura A, Taylor BC, Hanna A, Zhang S, Amancherla K, Tai W, Wright JJ, Wei SC, Opalenik SR, Toren AL, Rathmell JC, Ferrell PB, Phillips EJ, Mallal S, Johnson DB, Allison JP, Moslehi JJ, Balko JM. T cells specific for α-myosin drive immunotherapy-related myocarditis. Nature 2022; 611:818-826. [PMID: 36385524 PMCID: PMC9930174 DOI: 10.1038/s41586-022-05432-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022]
Abstract
Immune-related adverse events, particularly severe toxicities such as myocarditis, are major challenges to the utility of immune checkpoint inhibitors (ICIs) in anticancer therapy1. The pathogenesis of ICI-associated myocarditis (ICI-MC) is poorly understood. Pdcd1-/-Ctla4+/- mice recapitulate clinicopathological features of ICI-MC, including myocardial T cell infiltration2. Here, using single-cell RNA and T cell receptor (TCR) sequencing of cardiac immune infiltrates from Pdcd1-/-Ctla4+/- mice, we identify clonal effector CD8+ T cells as the dominant cell population. Treatment with anti-CD8-depleting, but not anti-CD4-depleting, antibodies improved the survival of Pdcd1-/-Ctla4+/- mice. Adoptive transfer of immune cells from mice with myocarditis induced fatal myocarditis in recipients, which required CD8+ T cells. The cardiac-specific protein α-myosin, which is absent from the thymus3,4, was identified as the cognate antigen source for three major histocompatibility complex class I-restricted TCRs derived from mice with fulminant myocarditis. Peripheral blood T cells from three patients with ICI-MC were expanded by α-myosin peptides. Moreover, these α-myosin-expanded T cells shared TCR clonotypes with diseased heart and skeletal muscle, which indicates that α-myosin may be a clinically important autoantigen in ICI-MC. These studies underscore the crucial role for cytotoxic CD8+ T cells, identify a candidate autoantigen in ICI-MC and yield new insights into the pathogenesis of ICI toxicity.
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Affiliation(s)
- Margaret L Axelrod
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wouter C Meijers
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elles M Screever
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Juan Qin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Mary Grace Carroll
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiaopeng Sun
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elie Tannous
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yueli Zhang
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayaka Sugiura
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brandie C Taylor
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ann Hanna
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shaoyi Zhang
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Kaushik Amancherla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Warren Tai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Cardiology, University of California, Los Angeles, CA, USA
| | - Jordan J Wright
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Spencer C Wei
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan R Opalenik
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Abigail L Toren
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey C Rathmell
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P Brent Ferrell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Australia
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Simon Mallal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Australia
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James P Allison
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Parker Institute for Cancer Immunotherapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javid J Moslehi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA.
| | - Justin M Balko
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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Schneider J, Sottmann L, Greinacher A, Hagen M, Kasper HU, Kuhnen C, Schlepper S, Schmidt S, Schulz R, Thiele T, Thomas C, Schmeling A. Postmortem investigation of fatalities following vaccination with COVID-19 vaccines. Int J Legal Med 2021; 135:2335-2345. [PMID: 34591186 PMCID: PMC8482743 DOI: 10.1007/s00414-021-02706-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023]
Abstract
Thorough postmortem investigations of fatalities following vaccination with coronavirus disease 2019 (COVID-19) vaccines are of great social significance. From 11.03.2021 to 09.06.2021, postmortem investigations of 18 deceased persons who recently received a vaccination against COVID-19 were performed. Vaxzevria was vaccinated in nine, Comirnaty in five, Spikevax in three, and Janssen in one person. In all cases, full autopsies, histopathological examinations, and virological analyses for the severe acute respiratory syndrome coronavirus 2 were carried out. Depending on the case, additional laboratory tests (anaphylaxis diagnostics, VITT [vaccine-induced immune thrombotic thrombocytopenia] diagnostics, glucose metabolism diagnostics) and neuropathological examinations were conducted. In 13 deceased, the cause of death was attributed to preexisting diseases while postmortem investigations did not indicate a causal relationship to the vaccination. In one case after vaccination with Comirnaty, myocarditis was found to be the cause of death. A causal relationship to vaccination was considered possible, but could not be proven beyond doubt. VITT was found in three deceased persons following vaccination with Vaxzevria and one deceased following vaccination with Janssen. Of those four cases with VITT, only one was diagnosed before death. The synopsis of the anamnestic data, the autopsy results, laboratory diagnostic examinations, and histopathological and neuropathological examinations revealed that VITT was the very likely cause of death in only two of the four cases. In the other two cases, no neuropathological correlate of VITT explaining death was found, while possible causes of death emerged that were not necessarily attributable to VITT. The results of our study demonstrate the necessity of postmortem investigations on all fatalities following vaccination with COVID-19 vaccines. In order to identify a possible causal relationship between vaccination and death, in most cases an autopsy and histopathological examinations have to be combined with additional investigations, such as laboratory tests and neuropathological examinations.
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Affiliation(s)
- Julia Schneider
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Lukas Sottmann
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Maximilian Hagen
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Hans-Udo Kasper
- Institute of Pathology at Clemens Hospital Münster, Münster, Germany
| | - Cornelius Kuhnen
- Institute of Pathology at Clemens Hospital Münster, Münster, Germany
| | - Stefanie Schlepper
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sven Schmidt
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Ronald Schulz
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Andreas Schmeling
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany.
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Law YM, Lal AK, Chen S, Čiháková D, Cooper LT, Deshpande S, Godown J, Grosse-Wortmann L, Robinson JD, Towbin JA. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e123-e135. [PMID: 34229446 DOI: 10.1161/cir.0000000000001001] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myocarditis remains a clinical challenge in pediatrics. Originally, it was recognized at autopsy before the application of endomyocardial biopsy, which led to a histopathology-based diagnosis such as in the Dallas criteria. Given the invasive and low-sensitivity nature of endomyocardial biopsy, its diagnostic focus shifted to a reliance on clinical suspicion. With the advances of cardiac magnetic resonance, an examination of the whole heart in vivo has gained acceptance in the pursuit of a diagnosis of myocarditis. The presentation may vary from minimal symptoms to heart failure, life-threatening arrhythmias, or cardiogenic shock. Outcomes span full resolution to chronic heart failure and the need for heart transplantation with inadequate clues to predict the disease trajectory. The American Heart Association commissioned this writing group to explore the current knowledge and management within the field of pediatric myocarditis. This statement highlights advances in our understanding of the immunopathogenesis, new and shifting dominant pathogeneses, modern laboratory testing, and use of mechanical circulatory support, with a special emphasis on innovations in cardiac magnetic resonance imaging. Despite these strides forward, we struggle without a universally accepted definition of myocarditis, which impedes progress in disease-targeted therapy.
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7
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Bajaj R, Sinclair HC, Patel K, Low B, Pericao A, Manisty C, Guttmann O, Zemrak F, Miller O, Longhi P, Proudfoot A, Lams B, Agarwal S, Marelli-Berg FM, Tiberi S, Cutino-Moguel T, Carr-White G, Mohiddin SA. Delayed-onset myocarditis following COVID-19. Lancet Respir Med 2021; 9:e32-e34. [PMID: 33617781 PMCID: PMC7906752 DOI: 10.1016/s2213-2600(21)00085-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Kush Patel
- Barts Health NHS Trust, London, UK; Institute of Cardiovascular Science, University College London, London, UK
| | - Ben Low
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ana Pericao
- Barts Health NHS Trust, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte Manisty
- Barts Health NHS Trust, London, UK; Institute of Cardiovascular Science, University College London, London, UK
| | - Oliver Guttmann
- Barts Health NHS Trust, London, UK; Institute of Cardiovascular Science, University College London, London, UK
| | | | - Owen Miller
- Guy's and St Thomas' NHS Foundation Trust, London, UK; Department of Women and Children's Health, School of Life Course Science, King's College London, St Thomas' Hospital, London, UK
| | - Paula Longhi
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alastair Proudfoot
- Barts Health NHS Trust, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Boris Lams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Federica M Marelli-Berg
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Simon Tiberi
- Barts Health NHS Trust, London, UK; Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Gerry Carr-White
- Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Biomedical Engineering and Imaging Sciences, Rayne Institute, King's College London, St Thomas' Hospital, London, UK
| | - Saidi A Mohiddin
- Barts Health NHS Trust, London, UK; Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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8
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Arguni E, Karyanti MR, Satari HI, Hadinegoro SR. Diphtheria outbreak in Jakarta and Tangerang, Indonesia: Epidemiological and clinical predictor factors for death. PLoS One 2021; 16:e0246301. [PMID: 33539453 PMCID: PMC7861411 DOI: 10.1371/journal.pone.0246301] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background In 2017, a diphtheria outbreak occurred in several provinces in Indonesia. The aim of this study was to identify predictors of mortality outcome of pediatric patients with clinical diphtheria. Methods A retrospective cohort study was conducted using patient medical records at five referral hospitals in the Province of Jakarta and one in Tangerang District, Banten Province during January 2017 to 31 August 2018. All children in the age group of 1–18 years old discharged with diagnosis of clinical diphtheria formed the study group. All anonymized patient data were evaluated for demographic issues, clinical features, immunization status, complication, laboratory profiles and outcome. Results A total of 283 patients with clinical diphtheria were included in the study group with case fatality rate of 3.5%. All mortal patients had the complication of myocarditis. Regression analyses revealed factors for predicting mortality. Incomplete primary diphtheria toxoid immunization, stridor, bull neck, leukocytosis ≥15 x109 cells/L and thrombocytopenia ≤150 x109 cells/L in each combination for 2 predictors modeling were correlated with death. Conclusions We report key predictors of mortality in pediatric patients with clinical diphtheria. The presence of these features when admitted to the hospital must be taken into account, because they can lead to fatal outcome.
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Affiliation(s)
- Eggi Arguni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- * E-mail:
| | - Mulya Rahma Karyanti
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Hindra Irawan Satari
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Sri Rezeki Hadinegoro
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
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9
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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10
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Agdamag ACC, Edmiston JB, Charpentier V, Chowdhury M, Fraser M, Maharaj VR, Francis GS, Alexy T. Update on COVID-19 Myocarditis. Medicina (Kaunas) 2020; 56:E678. [PMID: 33317101 PMCID: PMC7764165 DOI: 10.3390/medicina56120678] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.
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Affiliation(s)
- Arianne Clare C. Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.C.C.A.); (M.F.); (V.R.M.); (G.S.F.)
| | - Jonathan B. Edmiston
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (V.C.)
| | - Victoria Charpentier
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (V.C.)
| | | | - Meg Fraser
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.C.C.A.); (M.F.); (V.R.M.); (G.S.F.)
| | - Valmiki R. Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.C.C.A.); (M.F.); (V.R.M.); (G.S.F.)
| | - Gary S. Francis
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.C.C.A.); (M.F.); (V.R.M.); (G.S.F.)
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.C.C.A.); (M.F.); (V.R.M.); (G.S.F.)
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11
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Drobni ZD, Zafar A, Zubiri L, Zlotoff DA, Alvi RM, Lee C, Hartmann S, Gilman HK, Villani A, Nohria A, Groarke JD, Sullivan RJ, Reynolds KL, Zhang L, Neilan TG. Decreased Absolute Lymphocyte Count and Increased Neutrophil/Lymphocyte Ratio With Immune Checkpoint Inhibitor-Associated Myocarditis. J Am Heart Assoc 2020; 9:e018306. [PMID: 33190570 PMCID: PMC7763791 DOI: 10.1161/jaha.120.018306] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/07/2020] [Indexed: 12/21/2022]
Abstract
Background Myocarditis attributable to immune checkpoint inhibitor (ICI) therapy is a potentially fatal immune-related adverse event. Limited data have suggested an association between baseline and on-treatment absolute lymphocyte count (ALC) and neutrophil/lymphocyte ratio (NLR) and the development of other immune-related adverse events; there are no data characterizing the role of ALC and NLR in ICI-associated myocarditis. Methods and Results This was a case control study of 55 patients with ICI myocarditis and 55 controls without any post-ICI immune-related adverse events. We leveraged clinical testing, where patients underwent routine serial blood counts before and with each ICI cycle to compare the baseline and change in ALC and NLR between cases and controls. The association between the change in these parameters with clinical variables and major adverse cardiac events was also tested. In cases, there was a statistically significant decrease in ALC with myocarditis from baseline (1.6 thousands per cubic milliliter (K/μL); interquartile range, 1.1-1.9 K/μL) to admission (1.1 K/μL; interquartile range, 0.7-1.3 K/μL; P<0.001). Similarly, there was an increase in NLR from baseline (3.5; interquartile range, 2.3-5.4) to admission (6.6; interquartile range, 4.5-14.1; P<0.001). There was no statistically significant change in controls. In follow-up, there were 20 events; larger decreases in ALC (44.6% versus 18.2%; P<0.001) or increases in NLR (156.5% versus 65.1%; P=0.019) were associated with major adverse cardiac events. Conclusions A reduction in ALC and an increase in NLR was seen with ICI myocarditis. A greater decrease in ALC or increase in NLR was associated with subsequent major adverse cardiac events.
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Affiliation(s)
- Zsofia D. Drobni
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
- Cardiovascular Imaging Research Group, Heart and Vascular CenterSemmelweis UniversityBudapestHungary
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Amna Zafar
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Leyre Zubiri
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daniel A. Zlotoff
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Raza M. Alvi
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Charlotte Lee
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Sarah Hartmann
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Hannah K. Gilman
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Alexandra‐Chloe Villani
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Anju Nohria
- Cardio‐Oncology ProgramDivision of CardiologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - John D. Groarke
- Cardio‐Oncology ProgramDivision of CardiologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Ryan J. Sullivan
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Kerry L. Reynolds
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Lili Zhang
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMontefiore Medical CenterAlbert Einstein College of MedicineBronxNY
| | - Tomas G. Neilan
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
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12
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Yang H, Lu Y, Yang H, Yuan J. Clinical characteristics and treatment effects of astragalus injection in non-pediatric patients with acute fulminant myocarditis. Medicine (Baltimore) 2020; 99:e23062. [PMID: 33235067 PMCID: PMC7710263 DOI: 10.1097/md.0000000000023062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To explore the clinical characteristics of non-pediatric patients with acute fulminant myocarditis (AFM) and evaluate the treatment effects of astragalus injection on this disease.A total of 54 AFM patients were screened out from 586 patients with acute myocarditis, admitted to the department of cardiology between January 2011 to June 2018. The demographic and clinical data, investigations, treatments, and short-term outcomes were collected and retrospectively analyzed.The mean age of the 54 AFM patients was 34 ± 16.5 years old (range: 13-70 years), including 24 (44.5%) men and 30 (55.5%) women, with a high incidence in 2 age groups: 13-19 and 40-49 years old, despite an inverse trend to the increase of age. All these cases were admitted in emergency conditions: 26 (48.1%) cardiogenic shock, 18 (33.4%) malignant arrhythmias, 8 (14.8%) severe heart failure, and 2 (3.7%) acute pericardial tamponade. Apart from first-aid measures, 37 (68.5%) patients received astragalus injection. During hospitalization, 11 (20.4%) patients died, and 4 (36.3%) of them were from astragalus group while 7 (63.7%) of them from without-astragalus group (P=0.03). Furthermore, the levels of cardiac injury biomarkers, renal function and left ventricular ejection fraction of astragalus group were significantly improved compared with those of without-astragalus group at discharge (all P < .05).Middle-aged people were also prone to AFM. And cardiac shock was the most common, while acute pericardial tamponade was a rare presentation in non-pediatric AFM patients. Astragalus was a potential adjuvant medicine for the treatment of AFM.
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Abstract
BACKGROUND This is an update of a previous review. Case reports and case series have described dramatic responses to intravenous immunoglobulin (IVIG) in people with presumed viral myocarditis, and its administration has become commonplace. OBJECTIVES The primary objective of this review was to compare event-free (death, requirement for a cardiac transplant, or placement of a left ventricular assist device) or overall (death) survival of adults and children with presumed viral myocarditis treated with IVIG versus those who did not receive IVIG. A secondary objective was to determine if a group of patients with presumed viral myocarditis could be identified (on the basis of age, duration of symptoms, acuity of onset of symptoms, cardiac function at presentation, virological results, or the presence or absence of histological evidence of acute myocarditis on cardiac biopsy in patients in whom a biopsy was performed) who would be the most likely to benefit from IVIG. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, DARE, CINAHL, Web of Science Core Collection, and LILACS in July 2019, and two trial registries in November 2019. We contacted authors of trials and checked reference lists of relevant papers. We applied no language restrictions. SELECTION CRITERIA We included studies if (1) participants had a clinical diagnosis of acute myocarditis with a left ventricular ejection fraction (LVEF) ≤ 0.45, left ventricular end-diastolic diameter (LVEDD) > 2 standard deviations (SDs) above the norm, or a left ventricular shortening fraction (LVSF) > 2 SDs below the mean, with duration of cardiac symptoms < 6 months; (2) participants had no evidence of non-infectious or bacterial cardiac disease; and (3) participants were randomly assigned to receive at least 1 g/kg of IVIG versus no IVIG or placebo. We excluded studies if (1) participants had received immunosuppression before outcome assessment; or (2) onset of myocarditis was reported to have occurred < 6 months postpartum. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results and extracted data. We assessed risk of bias with the Cochrane 'Risk of bias' tool. We conducted meta-analysis for two outcomes (overall survival and improvement in LVEF) with two adult trials. Other meta-analyses were not possible because only three relevant trials were included, and researchers analysed markedly different populations and used different outcome measures. MAIN RESULTS In this update we added two trials to the two previously included trials. A quasi-randomised trial was previously included due to a paucity of evidence from randomised trials; however, with the addition of two new randomised trials, it was removed from this update. For two adult trials, the overall risk of bias was unclear with very low-certainty evidence for all outcomes. The first trial studied 62 adults with recent-onset dilated cardiomyopathy randomly assigned to receive IVIG or an equivalent volume of 0.1% albumin in a blinded fashion. The effect on event-free survival between groups was uncertain (risk ratio (RR) of any event 1.76, 95% confidence interval (CI) 0.48 to 6.40). The second trial studied 41 adults with acute myocarditis randomised to either high-dose IVIG (1 to 2 g/kg over two days) or no treatment. The IVIG group reported greater survival time after 60 days (no raw data, P < 0.01), but the evidence is uncertain. We pooled the reported number of deaths in both trials, with no evidence of a difference between groups (RR 0.91, 95% CI 0.23 to 3.62, I2 = 31%, very low-certainty evidence). The evidence on the effect of IVIG treatment on LVEF (pooled mean difference (MD) -0.01, 95% CI -0.06 to 0.05) after 12 months and an unknown time frame is uncertain. The results for functional capacity, assessed by peak oxygen consumption at 12 months, were uncertain (MD -0.80, 95% CI -4.57 to 2.97). The results for infusion-related side effects were also uncertain due to a very large CI (RR 20.29, 95% CI 1.25 to 329.93). Lastly, there was uncertain evidence addressing failure to attain complete recovery (RR 0.46, 95% CI 0.19 to 1.14). Evidence for improvement in LVEDD, left ventricular shortening fraction, and hospitalisation status in adults was not reported. In the single included paediatric trial, the overall risk of bias was low with very low-certainty evidence for all outcomes. The trial included 86 children in Egypt presenting with acute myocarditis. Children were randomly assigned to 1 g/kg IVIG daily for two consecutive days or placebo followed by echocardiography one and six months post randomisation for recording of LVEDD and LVSF. The evidence for overall survival after six months was uncertain (risk of death RR 0.48, 95% CI 0.20 to 1.15). The evidence was also uncertain for improvement in LVEDD and LVSF after six months (LVEDD MD -4.00, 95% CI -9.52 to 1.52; LVSF no raw data). Evidence for improvement in LVEF, functional capacity, side effects, complete recovery, and hospitalisation status in children was not reported. AUTHORS' CONCLUSIONS: Evidence from two trials of very low certainty and with unclear risk of bias provides contradictory evidence on the use of IVIG in the treatment of adults with presumed viral myocarditis. One trial reported that use of IVIG results in longer survival time after 60 days, whilst the other trial found that IVIG does not provide an appreciable benefit. The evidence of a difference in event-free or overall survival, LVEDD, or LVSF is of very low certainty in a single paediatric trial with a low risk of bias. Until higher-quality studies with low risk of bias and larger sample sizes have demonstrated benefit in a particular group of patients, the evidence for treatment with IVIG for presumed viral myocarditis is uncertain. Further studies of the pathophysiology of myocarditis would lead to improved diagnostic criteria, which would facilitate future research.
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Affiliation(s)
- Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Lisa Hartling
- Department of Pediatrics and the Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Ben Vandermeer
- Department of Pediatrics and the Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Meghan Sebastianski
- Pediatrics (AB SPOR Knowledge Translation Unit), University of Alberta, Edmonton, Canada
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Vágó H, Szabó L, Dohy Z, Czimbalmos C, Tóth A, Suhai FI, Bárczi G, Gyarmathy VA, Becker D, Merkely B. Early cardiac magnetic resonance imaging in troponin-positive acute chest pain and non-obstructed coronary arteries. Heart 2020; 106:992-1000. [PMID: 32447308 PMCID: PMC7306881 DOI: 10.1136/heartjnl-2019-316295] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE We assessed the diagnostic and prognostic implications of early cardiac magnetic resonance (CMR), CMR-based deformation imaging and conventional risk factors in patients with troponin-positive acute chest pain and non-obstructed coronary arteries. METHODS In total, 255 patients presenting between 2009 and 2019 with troponin-positive acute chest pain and non-obstructed coronary arteries who underwent CMR in ≤7 days were followed for a clinical endpoint of all-cause mortality. Cine movies, T2-weighted and late gadolinium-enhanced images were evaluated to establish a diagnosis of the underlying heart disease. Further CMR analysis, including left ventricular strain, was carried out. RESULTS CMR (performed at a mean of 2.7 days) provided the diagnosis in 86% of patients (54% myocarditis, 22% myocardial infarction (MI) and 10% Takotsubo syndrome and myocardial contusion (n=1)). The 4-year mortality for a diagnosis of MI, myocarditis, Takotsubo and normal CMR patients was 10.2%, 1.6%, 27.3% and 0%, respectively. We found a strong association between CMR diagnosis and mortality (log-rank: 24, p<0.0001). Takotsubo and MI as the diagnosis, age, hypertension, diabetes, female sex, ejection fraction, stroke volume index and most of the investigated strain parameters were univariate predictors of mortality; however, in the multivariate analysis, only hypertension and circumferential mechanical dispersion measured by strain analysis were independent predictors of mortality. CONCLUSIONS CMR performed in the early phase establishes the proper diagnosis in patients with troponin-positive acute chest pain and non-obstructed coronary arteries and provides additional prognostic factors. This may indicate that CMR could play an additional role in risk stratification in this patient population.
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Affiliation(s)
- Hajnalka Vágó
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Liliána Szabó
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsófia Dohy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Attila Tóth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - György Bárczi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - V Anna Gyarmathy
- EpiConsult LLC, Dover, Delaware, USA
- Johns Hopkins, Baltimore, Maryland, USA
| | - Dávid Becker
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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15
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Fischer K, Marggraf M, Stark AW, Kaneko K, Aghayev A, Guensch DP, Huber AT, Steigner M, Blankstein R, Reichlin T, Windecker S, Kwong RY, Gräni C. Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging. PLoS One 2020; 15:e0227134. [PMID: 31923225 PMCID: PMC6953836 DOI: 10.1371/journal.pone.0227134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Risk stratification of myocarditis is challenging due to variable clinical presentations. Cardiovascular magnetic resonance (CMR) is the primary non-invasive imaging modality to investigate myocarditis while electrocardiograms (ECG) are routinely included in the clinical work-up. The association of ECG parameters with CMR tissue characterisation and their prognostic value were investigated in patients with clinically suspected myocarditis. METHODS AND RESULTS Consecutive patients with suspected myocarditis who underwent CMR and ECG were analysed. Major adverse cardiovascular event (MACE) included all-cause death, hospitalisation for heart failure, heart transplantation, documented sustained ventricular arrhythmia, or recurrent myocarditis. A total of 587 patients were followed for a median of 3.9 years. A wide QRS-T angle, low voltage and fragmented QRS were significantly associated with late gadolinium enhancement. Further, a wide QRS-T angle, low voltage and prolonged QTc duration were associated with MACE in the univariable analysis. In a multivariable model, late gadolinium enhancement (HR: 1.90, 95%CI: 1.17-3.10; p = 0.010) and the ECG parameters of a low QRS voltage (HR: 1.86, 95%CI: 1.01-3.42; p = 0.046) and QRS-T-angle (HR: 1.01, 95%CI: 1.00-1.01; p = 0.029) remained independently associated with outcome. The cumulative incidence of MACE was incrementally higher when findings of both CMR and ECG were abnormal (p<0.001). CONCLUSION In patients with clinically suspected myocarditis, abnormal ECG parameters are associated with abnormal tissue characteristics detected by CMR. Further, ECG and CMR findings have independent prognostic implications for morbidity and mortality. Integrating both exams into clinical decision-making may play a role in risk stratification in this heterogeneous patient population.
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Affiliation(s)
- Kady Fischer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maximilian Marggraf
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W. Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kyoichi Kaneko
- Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Ayaz Aghayev
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Dominik P. Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian T. Huber
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Steigner
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Ron Blankstein
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raymond Y. Kwong
- Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
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16
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Ammirati E, Cipriani M, Moro C, Raineri C, Pini D, Sormani P, Mantovani R, Varrenti M, Pedrotti P, Conca C, Mafrici A, Grosu A, Briguglia D, Guglielmetto S, Perego GB, Colombo S, Caico SI, Giannattasio C, Maestroni A, Carubelli V, Metra M, Lombardi C, Campodonico J, Agostoni P, Peretto G, Scelsi L, Turco A, Di Tano G, Campana C, Belloni A, Morandi F, Mortara A, Cirò A, Senni M, Gavazzi A, Frigerio M, Oliva F, Camici PG. Clinical Presentation and Outcome in a Contemporary Cohort of Patients With Acute Myocarditis: Multicenter Lombardy Registry. Circulation 2019; 138:1088-1099. [PMID: 29764898 DOI: 10.1161/circulationaha.118.035319] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is controversy about the outcome of patients with acute myocarditis (AM), and data are lacking on how patients admitted with suspected AM are managed. We report characteristics, in-hospital management, and long-term outcome of patients with AM based on a retrospective multicenter registry from 19 Italian hospitals. METHODS A total of 684 patients with suspected AM and recent onset of symptoms (<30 days) were screened between May 2001 and February 2017. Patients >70 years of age and those >50 years of age without coronary angiography were excluded. The final study population comprised 443 patients (median age, 34 years; 19.4% female) with AM diagnosed by either endomyocardial biopsy or increased troponin plus edema and late gadolinium enhancement at cardiac magnetic resonance. RESULTS At presentation, 118 patients (26.6%) had left ventricular ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, whereas 325 (73.4%) had no such complications. Endomyocardial biopsy was performed in 56 of 443 (12.6%), and a baseline cardiac magnetic resonance was performed in 415 of 443 (93.7%). Cardiac mortality plus heart transplantation rates at 1 and 5 years were 3.0% and 4.1%. Cardiac mortality plus heart transplantation rates were 11.3% and 14.7% in patients with complicated presentation and 0% in uncomplicated cases (log-rank P<0.0001). Major AM-related cardiac events after the acute phase (postdischarge death and heart transplantation, sustained ventricular arrhythmias treated with electric shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8% at the 5-year follow-up, with a higher incidence in patients with complicated forms (10.8% versus 0% in uncomplicated AM; log-rank P<0.0001). β-Adrenoceptor blockers were the most frequently used medications both in complicated (61.9%) and in uncomplicated forms (53.8%; P=0.18). After a median time of 196 days, 200 patients had follow-up cardiac magnetic resonance, and 8 of 55 (14.5%) with complications at presentation had left ventricular ejection fraction <50% compared with 1 of 145 (0.7%) of those with uncomplicated presentation. CONCLUSIONS In this contemporary study, overall serious adverse events after AM were lower than previously reported. However, patients with left ventricular ejection fraction <50%, ventricular arrhythmias, or low cardiac output syndrome at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent left ventricular systolic dysfunction.
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Affiliation(s)
| | - Manlio Cipriani
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | | | - Claudia Raineri
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Daniela Pini
- Humanitas Clinical and Research Center, Rozzano, Italy (D.P., R.M.)
| | - Paola Sormani
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | | | - Marisa Varrenti
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Patrizia Pedrotti
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Cristina Conca
- San Carlo Borromeo Hospital, Milan, Italy (C. Conca, A. Mafrici)
| | - Antonio Mafrici
- San Carlo Borromeo Hospital, Milan, Italy (C. Conca, A. Mafrici)
| | - Aurelia Grosu
- Papa Giovanni XXIII Hospital, Bergamo, Italy (A. Grosu, M.S.)
| | | | - Silvia Guglielmetto
- San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy (S.G., G.B.P.)
| | - Giovanni B Perego
- San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy (S.G., G.B.P.)
| | - Stefania Colombo
- Azienda Socio Sanitaria Territoriale Valle Olona, Gallarate Hospital, Italy (S.C., S.I.C.)
| | - Salvatore I Caico
- Azienda Socio Sanitaria Territoriale Valle Olona, Gallarate Hospital, Italy (S.C., S.I.C.)
| | - Cristina Giannattasio
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
- University of Milano-Bicocca, Milan, Italy (C.G.)
| | | | | | - Marco Metra
- Spedali Civili, University of Brescia, Italy (V.C., M.M., C.L.)
| | - Carlo Lombardi
- Spedali Civili, University of Brescia, Italy (V.C., M.M., C.L.)
| | - Jeness Campodonico
- Monzino Center, Istituto di Ricerca e Cura a Carattere Scientifico, Milan, Italy (J.C., P.A.)
| | - Piergiuseppe Agostoni
- Monzino Center, Istituto di Ricerca e Cura a Carattere Scientifico, Milan, Italy (J.C., P.A.)
- Department of Clinical Sciences and Community Health, University of Milan, Italy (P.A.)
| | - Giovanni Peretto
- Vita Salute University and San Raffaele Hospital, Milan, Italy (G.P., P.G.C.)
| | - Laura Scelsi
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Annalisa Turco
- Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico San Matteo and the University of Pavia, Italy (C.R., L.S., A.T.)
| | - Giuseppe Di Tano
- Azienda Socio Sanitaria Territoriale Cremona, Cremona Hospital, Italy (G.D.T.)
| | | | | | - Fabrizio Morandi
- Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (F.M.)
| | | | | | - Michele Senni
- Papa Giovanni XXIII Hospital, Bergamo, Italy (A. Grosu, M.S.)
| | - Antonello Gavazzi
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation Ospedale Papa Giovanni XXIII, Bergamo, Italy (A. Gavazzi)
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.C., M.C., P.S., M.V., P.P., C.G., M.F., F.O.)
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy (G.P., P.G.C.)
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17
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Wolf AE, Marino BS, Chaouki AS, Andrei AC, Gossett JG. Pediatric Acute Myocarditis: Predicting Hemodynamic Compromise at Presentation to Health Care. Hosp Pediatr 2019; 9:455-459. [PMID: 31147385 DOI: 10.1542/hpeds.2018-0212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The clinical spectrum of pediatric acute myocarditis ranges from minimal symptoms with intact hemodynamics to rapid cardiovascular collapse and death. We sought to identify factors on initial presentation associated with subsequent hemodynamic compromise. METHODS We performed a retrospective cohort study of patients with acute myocarditis at a freestanding pediatric hospital from 2007 to 2016. We defined 2 cohorts: high-acuity patients with hemodynamic compromise defined as requiring inotropic or vasoactive medications, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, ventricular assist devices, or transplant or who died and low-acuity patients without these interventions. We collected the first recorded set of vital signs, symptoms, laboratory values, and chest radiograph, electrocardiogram, and echocardiography results. Univariate analysis was performed, and 2 multivariable logistic regression models were created to discriminate between cohorts. RESULTS A total of 74 patients were included: 33 high acuity and 41 low acuity. There were significant differences in demographics, symptoms, and physical examination, laboratory, electrocardiogram, and echocardiography findings between high- and low-acuity cohorts. Multivariable logistic regression models were highly discriminate in predicting those in the high-acuity cohort. The first model included presence of tachycardia, tachypnea, creatinine, and cardiomegaly on chest radiograph (area under the curve = 0.913). The second model added the presence of pericardial effusion to the above variables (area under the curve = 0.964). CONCLUSIONS Models based on factors available at initial presentation with acute myocarditis are predictive of subsequent hemodynamic compromise. If our results can be validated in a multicenter study, these models may help disposition patients with suspected acute myocarditis (with those who meet model criteria being admitted to centers capable of rapidly providing extracorporeal membrane oxygenation, ventricular assist devices, and heart transplant evaluation).
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Affiliation(s)
- Ashley E Wolf
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Bradley S Marino
- Department of Pediatrics, Feinberg School of Medicine and
- Divisions of Critical Care and
| | - Ahmad Sami Chaouki
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | | | - Jeffrey G Gossett
- Division of Cardiology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California
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18
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Yang L, Ye L, Fan Y, He W, Zong Q, Zhao W, Lin R. Outcomes following venoarterial extracorporeal membrane oxygenation in children with refractory cardiogenic disease. Eur J Pediatr 2019; 178:783-793. [PMID: 30834480 DOI: 10.1007/s00431-019-03352-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 11/26/2022]
Abstract
Retrospective analysis was performed at an affiliated university children's hospital with consecutive patients receiving a venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock from July 2007 to May 2018. Fifty-six patients underwent VA-ECMO for refractory cardiogenic shock with the median age of 39.0 (1.5, 103.5) months were included. Median ECMO duration was 87 h, and the median length of hospital stay was 22 days. Successful ECMO weaning rate was 68%. Thirty-day mortality in this cohort was 39% (22/56), among which the mortality of fulminant myocarditis and postcardiotomy cardiogenic shock (PCS) were 23% (6/26) and 52% (12/23), respectively. Multivariate Cox proportional hazard regression analysis identified prolonged prothrombin time (PT) > 6 s and elevated lactate level 24 h after ECMO initiation were associated with 30-day mortality.Conclusions: Pediatric VA-ECMO for refractory cardiogenic shock appears to be a satisfactory salvage therapy to various fatal diseases in this retrospective study. Prolonged PT > 6 s and elevated lactate level 24 h were significant predictors of 30-day mortality. What is Known: • VA-ECMO is a salvage therapy for refractory cardiogenic shock in pediatrics. What is New: • Prothrombin time > 6 s was a significant predictor of 30-day mortality. • Elevated lactate level 24 h was a significant predictor of 30-day mortality.
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Affiliation(s)
- Lijun Yang
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Lifen Ye
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Yong Fan
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Wenlong He
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Qing Zong
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Wenting Zhao
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China
| | - Ru Lin
- Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart Institute, Zhejiang University School of Medicine Children's Hospital, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, Zhejiang, China.
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19
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Adegbala O, Olagoke O, Akintoye E, Adejumo AC, Oluwole A, Jara C, Williams K, Briasoulis A, Afonso L. Predictors, Burden, and the Impact of Arrhythmia on Patients Admitted for Acute Myocarditis. Am J Cardiol 2019; 123:139-144. [PMID: 30539745 DOI: 10.1016/j.amjcard.2018.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 02/04/2023]
Abstract
A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention.
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Affiliation(s)
- Oluwole Adegbala
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, New Jersey.
| | - Olakanmi Olagoke
- Department of Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Emmanuel Akintoye
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Adegbola Oluwole
- Department of Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
| | - Christina Jara
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, New Jersey
| | - Karlene Williams
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, New Jersey
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Luis Afonso
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan
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20
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Coverstone ED, Bach RG, Chen L, Bierut LJ, Li AY, Lenzini PA, O'Neill HC, Spertus JA, Sucharov CC, Stitzel JA, Schilling JD, Cresci S. A novel genetic marker of decreased inflammation and improved survival after acute myocardial infarction. Basic Res Cardiol 2018; 113:38. [PMID: 30097758 PMCID: PMC6292447 DOI: 10.1007/s00395-018-0697-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
The CHRNA5 gene encodes a neurotransmitter receptor subunit involved in multiple processes, including cholinergic autonomic nerve activity and inflammation. Common variants in CHRNA5 have been linked with atherosclerotic cardiovascular disease. Association of variation in CHRNA5 and specific haplotypes with cardiovascular outcomes has not been described. The aim of this study was to examine the association of CHRNA5 haplotypes with gene expression and mortality among patients with acute myocardial infarction (AMI) and explore potential mechanisms of this association. Patients (N = 2054) hospitalized with AMI were genotyped for two common variants in CHRNA5. Proportional hazard models were used to estimate independent association of CHRNA5 haplotype with 1-year mortality. Both individual variants were associated with mortality (p = 0.0096 and 0.0004, respectively) and were in tight LD (D' = 0.99). One haplotype, HAP3, was associated with decreased mortality one year after AMI (adjusted HR = 0.42, 95% CI 0.26, 0.68; p = 0.0004). This association was validated in an independent cohort (N = 637) of post-MI patients (adjusted HR = 0.23, 95% CI 0.07, 0.79; p = 0.019). Differences in CHRNA5 expression by haplotype were investigated in human heart samples (n = 28). Compared with non-carriers, HAP3 carriers had threefold lower cardiac CHRNA5 mRNA expression (p = 0.023). Circulating levels of the inflammatory marker hsCRP were significantly lower in HAP3 carriers versus non-carriers (3.43 ± 4.2 versus 3.91 ± 5.1; p = 0.0379). Activation of the inflammasome, an important inflammatory complex involved in cardiovascular disease that is necessary for release of the pro-inflammatory cytokine IL-1 β, was assessed in bone marrow-derived macrophages (BMDM) from CHRNA5 knockout mice and wild-type controls. In BMDM from CHRNA5 knockout mice, IL-1β secretion was reduced by 50% compared to wild-type controls (p = 0.004). Therefore, a common haplotype of CHRNA5 that results in reduced cardiac expression of CHRNA5 and attenuated macrophage inflammasome activation is associated with lower mortality after AMI. These results implicate CHRNA5 and the cholinergic anti-inflammatory pathway in survival following AMI.
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Affiliation(s)
- Edward D Coverstone
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8086, Saint Louis, MO, 63110, USA
| | - Richard G Bach
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8086, Saint Louis, MO, 63110, USA
| | - LiShiun Chen
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Laura J Bierut
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Allie Y Li
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8086, Saint Louis, MO, 63110, USA
| | - Petra A Lenzini
- Statistical Genomics Division, Department of Genetics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Heidi C O'Neill
- Institute for Behavioral Genetics, University of Colorado, Boulder, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | - Carmen C Sucharov
- Cardiology Division, Department of Medicine, University of Colorado Denver, Aurora, USA
| | - Jerry A Stitzel
- Institute for Behavioral Genetics, University of Colorado, Boulder, USA
| | - Joel D Schilling
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8086, Saint Louis, MO, 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Sharon Cresci
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8086, Saint Louis, MO, 63110, USA.
- Department of Genetics, Washington University School of Medicine, Saint Louis, MO, USA.
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21
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Tschöpe C, Van Linthout S, Klein O, Mairinger T, Krackhardt F, Potapov EV, Schmidt G, Burkhoff D, Pieske B, Spillmann F. Mechanical Unloading by Fulminant Myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA Concepts. J Cardiovasc Transl Res 2018; 12:116-123. [PMID: 30084076 PMCID: PMC6497621 DOI: 10.1007/s12265-018-9820-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/18/2018] [Indexed: 12/19/2022]
Abstract
Mechanical circulatory support (MCS) is often required to stabilize patients with acute fulminant myocarditis with cardiogenic shock. This review gives an overview of the successful use of left-sided Impella in the setting of fulminant myocarditis and cardiogenic shock as the sole means of MCS as well as in combination with right ventricular (RV) support devices including extracorporeal life support (ECLS) (ECMELLA) or an Impella RP (BI-PELLA). It further provides evidence from endomyocardial biopsies that in addition to giving adequate support, LV unloading by Impella exhibits disease-modifying effects important for myocardial recovery (i.e., bridge-to-recovery) achieved by this newly termed “prolonged Impella” (PROPELLA) concept in which LV-IMPELLA 5.0, implanted via an axillary approach, provides support in awake, mobilized patients for several weeks. Finally, this review addresses the question of how to define the appropriate time point for weaning strategies and for changing or discontinuing unloading in fulminant myocarditis.
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Affiliation(s)
- Carsten Tschöpe
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany.
- Charité, University Medicine Berlin, Berlin-Brandenburg Center for Regenerative Therapy (BCRT), Campus Virchow Klinikum, Berlin, Germany.
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany.
| | - Sophie Van Linthout
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany
- Charité, University Medicine Berlin, Berlin-Brandenburg Center for Regenerative Therapy (BCRT), Campus Virchow Klinikum, Berlin, Germany
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany
| | - Oliver Klein
- Charité, University Medicine Berlin, Berlin-Brandenburg Center for Regenerative Therapy (BCRT), Campus Virchow Klinikum, Berlin, Germany
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany
| | | | - Florian Krackhardt
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany
| | - Evgenij V Potapov
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Gunther Schmidt
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany
| | | | - Burkert Pieske
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany
- Department of Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Frank Spillmann
- Charité, University Medicine Berlin, Department of Cardiology, Campus Virchow Klinikum, Berlin, Germany
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany
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22
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Abstract
Fulminant myocarditis is a severe cardiac emergency that may lead to death if effective cardiopulmonary supports are not provided. This study aimed to evaluate the prognostic predictors in patients with fulminant myocarditis.We retrospectively analyzed the clinical characteristics, complications, laboratory findings, treatments, as well as electrocardiographic and echocardiographic data of 73 consecutive subjects diagnosed with fulminant myocarditis from June 2012 to June 2016. Logistic regression analysis was used to identify the independent predictive factors of nonsurvivor fulminant myocarditis.Ten patients and 63 patients were assigned to the nonsurvivor and survivor fulminant myocarditis groups, respectively. Patients in the nonsurvivor fulminant myocarditis group had higher heart rates; were more likely to develop clinical complications and supraventricular tachycardia (SVT); and had higher serum creatinine (Scr) level, and had higher white blood cell (WBC) counts, and lower abbreviated estimated glomerular filtration rates (eGFR) than the patients in the survivor fulminant myocarditis group. Moreover, we observed larger left atrium dimension (LAd), larger left ventricular end systolic dimensions, and lower left ventricular ejection fraction in the patients from the nonsurvivor fulminant myocarditis group than in those from the other group. A logistic regression model was constructed and demonstrated that eGFR and LAd were 2 independent predictors of mortality in patients with fulminant myocarditis.Higher heart rates, higher incidences of clinical complication, SVT, higher admission levels of Scr and eGFR, higher WBC counts, higher Scr and eGFR at stage of most severe renal damage, and abnormal echocardiographic findings were associated with high risk of mortality in patients with fulminant myocarditis. The major finding was that eGFR and LAd were independent predictors for in-hospital mortality in patients with fulminant myocarditis.
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23
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Abstract
Bacterial myocarditis is an uncommon condition and only a few fatal cases in adults are reported in the scientific literature. Death from acute bacterial myocarditis in children is extremely rare. We report an unusual case of fatal bacterial myocarditis in a seven-year-old girl, who had a history of cough for a month and fever for two days. She was given symptomatic treatment by a local physician without suspecting her clinical condition. Her condition rapidly deteriorated and she was brought in dead to the hospital. Autopsy revealed pyogenic bacterial myocarditis associated with bilateral lobar pneumonia caused by Gram-positive cocci. Death from bacterial myocarditis can be prevented by early diagnosis and appropriate antibiotics.
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Affiliation(s)
- Asit K Sikary
- 1 Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Asit R Mridha
- 2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Chittaranjan Behera
- 1 Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India
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24
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Te ALD, Wu TC, Lin YJ, Chen YY, Chung FP, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chien KL, Lin CY, Chang YT, Chen SA. Increased risk of ventricular tachycardia and cardiovascular death in patients with myocarditis during the long-term follow-up: A national representative cohort from the National Health Insurance Research Database. Medicine (Baltimore) 2017; 96:e6633. [PMID: 28471960 PMCID: PMC5419906 DOI: 10.1097/md.0000000000006633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The incidence of acute myocarditis complicated with ventricular tachycardia (VT) is unknown. This study aimed to investigate the association between myocarditis and the incidence of VT and mortality. We also aimed to determine the independent predictors that increased the VT risk in those patients. From 2000 to 2004, 13,250 patients with a history of myocarditis were identified from the Taiwan National Health Insurance Research Database. The same number of individuals without heart disease with a matched sex and underlying diseases were selected as the control group. The long-term risks of life-threatening ventricular arrhythmias and mortality in patients with a history of myocarditis were investigated by an adjusted Cox proportional hazards regression. After a mean follow-up of 10.4 ± 2.94 years (interquartile range: 12, 10.19-12), the myocarditis patients showed a higher incidence of new onset VT events compared with healthy controls (5.4% [519 per 100,000 person-year] in the myocarditis group vs, 0.47% [43 per 100,000 person-year] in the healthy controls; adjusted hazard ratio [HR]: 16.1, 95% confidence interval [CI]: 12.4-20.9; P < .001). A higher incidence of cardiovascular death was noted in the myocarditis group than healthy controls (6.52% vs 3.18%; HR: 2.42, 95% CI: 2.14-2.73; P < .001) after adjusting for the multivariate confounders including sex, age, underlying comorbidities, and medications. The results of this study suggested that there was higher incidence of life-threatening VT and mortality during the very long-term follow-up in patients with a history of myocarditis. Future work should focus on an in-depth risk stratification of VT in myocarditis patients.
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Affiliation(s)
- Abigail Louise D. Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
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25
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Spieker M, Haberkorn S, Gastl M, Behm P, Katsianos S, Horn P, Jacoby C, Schnackenburg B, Reinecke P, Kelm M, Westenfeld R, Bönner F. Abnormal T2 mapping cardiovascular magnetic resonance correlates with adverse clinical outcome in patients with suspected acute myocarditis. J Cardiovasc Magn Reson 2017; 19:38. [PMID: 28351402 PMCID: PMC5370450 DOI: 10.1186/s12968-017-0350-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 03/01/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND While most patients recover from suspected acute myocarditis (sAMC) some develop progressive disease with 5-year mortality up to 20%. Recently, parametric Cardiovascular Magnetic Resonance (CMR) approaches, quantifying native T1 and T2 relaxation time, have demonstrated the ability to increase diagnostic accuracy. However, prognostic implications of T2 values in this cohort are unknown. The purpose of the study was to investigate the prognostic relevance of elevated CMR T2 values in patients with sAMC. METHODS AND RESULTS We carried out a prospective study in 46 patients with sAMC defined by current ESC recommendations. A combined endpoint was defined by the occurrence of at least one major adverse cardiac event (MACE) and hospitalisation for heart failure. Event rate was 24% (n = 11) for 1-year-MACE and hospitalisation. A follow-up after 11 ± 7 months was performed in 98% of the patients. Global T2 values were significantly increased at acute stage of disease compared to controls and decreased over time. During acute disease, elevated global T2 time (odds ratio 6.3, p < 0.02) as well as myocardial fraction with T2 time >80 ms (odds ratio 4.9, p < 0.04) predicted occurrence of the combined endpoint. Patients with clinical recovery revealed significantly decreased T2 relaxation times at follow-up examinations; however, T2 values were still elevated compared to healthy controls. CONCLUSION Assessment of myocardial T2 relaxation times at initial presentation facilitates CMR-based risk stratification in patients with acute myocarditis. T2 Mapping may emerge as a new tool to monitor inflammatory myocardial injuries during the course of disease.
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Affiliation(s)
- Maximilian Spieker
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Sebastian Haberkorn
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Mareike Gastl
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Patrick Behm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Stratis Katsianos
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christoph Jacoby
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | | | - Petra Reinecke
- Institute of Pathology, Heinrich Heine University, Duesseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute Düsseldorf, Duesseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Florian Bönner
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence and Etiology of Sudden Cardiac Arrest and Death in High School Athletes in the United States. Mayo Clin Proc 2016; 91:1493-1502. [PMID: 27692971 DOI: 10.1016/j.mayocp.2016.07.021] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/03/2016] [Accepted: 07/25/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the incidence and etiology of sudden cardiac arrest and death (SCA/D) in US high school athletes. PATIENTS AND METHODS A prospective media database of SCA/D was queried for cases aged 14 to 18 years from 7 states over 6 school years (September 1, 2007, to August 30, 2013). Event details were investigated to determine participation on a high school athletic team, sex, sport, and occurrence during school-sponsored activity or exertion. National sports participation numbers were used and a conversion factor was applied to account for multisport athletes. Autopsy reports were reviewed and cause of death was adjudicated by an expert panel. RESULTS A total of 16,390,409 million athlete-seasons representing 6,974,640 athlete-years (AY) were examined, encompassing 36% of the total US high school athlete population. A total of 104 cases of SCA/D were identified (35 SCA with survival and 69 sudden cardiac deaths [SCDs]). The rate of SCD was 1:101,082 AY and of SCA/D 1:67,064 AY. Eighty-eight percent (92) of events occurred in male athletes. The rate of SCA/D in male athletes was 1:44,832 AY and in female athletes 1:237,510 AY (incidence rate ratio, 5.3; 95% CI, 2.9-10.6; P<.001). Men's basketball was the highest risk sport with an SCA/D incidence of 1:37,087 AY followed by men's football at 1:86,494 AY. Men's basketball and football athletes accounted for 57% (39) of deaths. Eighty percent of SCDs (55 of 69) were exertional and 55% (38 of 69) occurred while playing for a school-sponsored team. Autopsy reports were obtained in 73% (50) of cases. The most common findings of autopsy were idiopathic left ventricular hypertrophy or possible cardiomyopathy (13 of 50 [26%]), autopsy-negative sudden unexplained death (9 of 50 [18%]), hypertrophic cardiomyopathy (7 of 50 [14%]), and myocarditis (7 of 50 [14%]). CONCLUSION The rate of SCA/D in male high school athletes was 1:44,832 AY, with almost half due to possible or confirmed cardiomyopathy disease. It is likely that many cases were not identified because of reliance on media reports, and these numbers represent a minimum estimate.
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Affiliation(s)
| | - Irfan M Asif
- University of South Carolina Greenville, Greenville, SC
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Lucas JF. Sudden Cardiac Death in School Aged Athletes. J S C Med Assoc 2016; 112:185-189. [PMID: 30281959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P, Botta L, Milazzo F, Actis Dato G, Casabona R, Casali G, Musumeci F, De Bonis M, Zangrillo A, Alfieri O, Pellegrini C, Mazzola S, Coletti G, Vizzardi E, Bianco R, Gerosa G, Massetti M, Caldaroni F, Pilato E, Pacini D, Di Bartolomeo R, Marinelli G, Sponga S, Livi U, Mauro R, Mariscalco G, Beghi C, Miceli A, Glauber M, Pappalardo F, Russo CF. Venoarterial Extracorporeal Membrane Oxygenation for Acute Fulminant Myocarditis in Adult Patients: A 5-Year Multi-Institutional Experience. Ann Thorac Surg 2015; 101:919-26. [PMID: 26518372 DOI: 10.1016/j.athoracsur.2015.08.014] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 07/31/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.
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Affiliation(s)
- Roberto Lorusso
- Cardiac Surgery Unit, Spedali Civili Hospital, Brescia, Italy.
| | | | - Sandro Gelsomino
- Cardiovascular Research Centre, Careggi Hospital, Florence, Italy
| | - Fabio Barili
- Cardiac Surgery Unit, S. Anna Hospital, Cuneo, Italy
| | | | - Parise Orlando
- Cardiovascular Research Centre, Careggi Hospital, Florence, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Niguarda Hospital, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gino Gerosa
- Cardiac Surgery Unit, University Hospital, Padua, Italy
| | | | | | | | | | | | | | | | | | | | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | | | - Antonio Miceli
- Pasquinucci Hospital Fondazione Monasterio, Massa, Italy
| | - Mattia Glauber
- Pasquinucci Hospital Fondazione Monasterio, Massa, Italy
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Rosa VEE, Lopes ASSA, Accorsi TAD, Fernandes JRC, Spina GS, Sampaio RO, Bacal F, Tarasoutchi F. Heart Transplant in Patients with Predominantly Rheumatic Valvular Heart Disease. J Heart Valve Dis 2015; 24:629-634. [PMID: 26897843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY International records indicate that only 2.6% of patients with heart transplants have valvular heart disease. The study aim was to evaluate the epidemiological and clinical profile of patients with valvular heart disease undergoing heart transplantation. METHODS Between 1985 and 2013, a total of 569 heart transplants was performed at the authors' institution. Twenty patients (13 men, seven women; mean age 39.5 +/- 15.2 years) underwent heart transplant due to structural (primary) valvular disease. Analyses were made of the patients' clinical profile, laboratory data, echocardiographic and histopathological data, and mortality and rejection. RESULTS Of the patients, 18 (90%) had a rheumatic etiology, with 85% having undergone previous valve surgery (45% had one or more operations), and 95% with a normal functioning valve prosthesis at the time of transplantation. Atrial fibrillation was present in seven patients (35%), while nine (45%) were in NYHA functional class IV and eight (40%) in class III. The indication for cardiac transplantation was refractory heart failure in seven patients (35%) and persistent NYHA class III/IV in ten (50%). The mean left ventricular ejection fraction (LVEF) was 26.6 +/- 7.9%. The one-year mortality was 20%. Histological examination of the recipients' hearts showed five (27.7%) to have reactivated rheumatic myocarditis without prior diagnosis at the time of transplantation. Univariate analysis showed that age, gender, LVEF, rheumatic activity and rejection were not associated with mortality at one year. CONCLUSION Among the present patient cohort, rheumatic heart disease was the leading cause of heart transplantation, and a significant proportion of these patients had reactivated myocarditis diagnosed in the histological analyses. Thus, it appears valid to investigate the existence of rheumatic activity, especially in valvular cardiomyopathy with severe systolic dysfunction before transplantation.
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Sanguineti F, Garot P, Mana M, O'h-Ici D, Hovasse T, Unterseeh T, Louvard Y, Troussier X, Morice MC, Garot J. Cardiovascular magnetic resonance predictors of clinical outcome in patients with suspected acute myocarditis. J Cardiovasc Magn Reson 2015; 17:78. [PMID: 26318624 PMCID: PMC4553007 DOI: 10.1186/s12968-015-0185-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/17/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The natural history of acute myocarditis (AM) remains highly variable and predictors of outcome are largely unknown. The objectives were to determine the potential value of various cardiovascular magnetic resonance (CMR) parameters for the prediction of adverse long-term outcome in patients presenting with suspected AM. METHODS In a single-centre longitudinal prospective study, 203 routine consecutive patients with an initial CMR-based diagnosis of AM (typical Late Gadolinium Enhancement, LGE) were followed over a mean period of 18.9 ± 8.2 months. Various CMR parameters were evaluated as potential predictors of outcome. The primary endpoint was defined as the occurrence of at least one of the combined Major Adverse Clinical Events (MACE) (cardiac death or aborted sudden cardiac death, cardiac transplantation, sustained documented ventricular tachycardia, heart failure, recurrence of acute myocarditis, and the need for hospitalization for cardiac causes). RESULTS The vast majority of patients (N = 143,70 %) presented with chest pain, mild to moderate troponin elevation and ST-segment or T wave abnormalities. Various CMR parameters were evaluated on initial CMR performed 3 ± 2 days after acute clinical presentation (LV functional parameters, presence/extent of edema on T2 CMR, and extent of late gadolinium enhancement lesions). Out of the 203 patients, 22 experienced at least one major cardiovascular event (10.8 %) during follow-up for a total of 31 major cardiovascular events. Among all CMR parameters, the only independent CMR predictor of adverse clinical outcome by multivariate analysis was an initial alteration of LVEF (p = 0.04). CONCLUSIONS In routine consecutive patients without severe hemodynamic compromise and a CMR-based diagnosis of AM, various CMR parameters such as the presence and extent of myocardial edema and the extent of late gadolinium-enhanced LV myocardial lesions were not predictive of outcome. The only independent CMR predictor of adverse clinical outcome was an initial alteration of LVEF.
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Affiliation(s)
- Francesca Sanguineti
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Philippe Garot
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Melina Mana
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Darach O'h-Ici
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Thomas Hovasse
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Thierry Unterseeh
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Yves Louvard
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Xavier Troussier
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Marie-Claude Morice
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
| | - Jérôme Garot
- The Hôpital Privé Jacques Cartier - ICPS, CMR Department, Ramsay-Générale de Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Maleszewski JJ, Orellana VM, Hodge DO, Kuhl U, Schultheiss HP, Cooper LT. Long-term risk of recurrence, morbidity and mortality in giant cell myocarditis. Am J Cardiol 2015; 115:1733-8. [PMID: 25882774 DOI: 10.1016/j.amjcard.2015.03.023] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Joseph J Maleszewski
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Victor M Orellana
- Department of Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Uwe Kuhl
- Department of Cardiology, Charite Hospital, Benjamin Franklin Campus, Berlin, Germany
| | | | - Leslie T Cooper
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Harris LC. Newer aspects of cardiomyopathies. Adv Cardiol 2015; 13:44-52. [PMID: 4532465 DOI: 10.1159/000395525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Isogai T, Yasunaga H, Matsui H, Tanaka H, Horiguchi H, Fushimi K. Effect of intravenous immunoglobulin for fulminant myocarditis on in-hospital mortality: propensity score analyses. J Card Fail 2015; 21:391-397. [PMID: 25639690 DOI: 10.1016/j.cardfail.2015.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 12/31/2014] [Accepted: 01/23/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fulminant myocarditis (FM) is a rare but life-threatening disease. Intravenous immunoglobulin (IVIG) is not recommended for acute or chronic myocarditis in Western nations owing to the lack of rigorous evidence, but it is widely used in other countries, including Japan. This nationwide retrospective cohort study focused on evaluating the effect of IVIG in FM patients. METHODS AND RESULTS Using the Diagnosis Procedure Combination database in Japan, we identified 603 FM patients aged ≥16 years who received mechanical circulatory support within 7 days after admission. We performed propensity score analyses to compare the in-hospital mortality and total costs between IVIG users (n = 220; 36.5%) and nonusers (n = 383; 63.5%). Among propensity score-matched patients (164 pairs), there was no significant difference in in-hospital mortality between IVIG users and nonusers (36.6% vs 37.2%; P = .909). A multivariable logistic regression analysis showed no significant association between IVIG use and in-hospital mortality (adjusted odds ratio 0.91; 95% confidence interval 0.52 to 1.58; P = .733). The median total costs were significantly higher for IVIG users than for nonusers (US $44,226 vs $33,280; P < .001). CONCLUSION IVIG for FM was not significantly associated with a decrease in in-hospital mortality.
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Affiliation(s)
- Toshiaki Isogai
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan; Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Rady HI, Zekri H. Prevalence of myocarditis in pediatric intensive care unit cases presenting with other system involvement. J Pediatr (Rio J) 2015; 91:93-7. [PMID: 25264903 DOI: 10.1016/j.jped.2014.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/16/2014] [Accepted: 05/28/2014] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To assess children with myocarditis, the frequency of various presenting symptoms, and the accuracy of different investigations in the diagnosis. METHODS This was an observational study of 63 patients admitted to PICU with non-cardiac diagnosis. Cardiac enzymes, chest-X ray, echocardiography, and electrocardiogram were performed to diagnose myocarditis among those patients. RESULTS There were 16 cases of definite myocarditis. The age distribution was non-normal, with median of 5.5 months (3.25-21). Of the 16 patients who were diagnosed with myocarditis, 62.5% were originally diagnosed as having respiratory problems, and there were more females than males. Among the present cases, the accuracy of cardiac enzymes (cardiac troponin T [cTn] and creatine phosphokinase MB [CKMB]) in the diagnosis of myocarditis was only 63.5%, while the accuracy of low fractional shortening and of chest-X ray cardiomegaly was 85.7 and 80.9%; respectively. Cardiac troponin folds 2.02 had positive predictive value of 100%, negative predictive value of 88.7%, specificity of 100%, sensitivity of 62.5%, and accuracy of 90.5%. CONCLUSIONS Children with myocarditis present with symptoms that can be mistaken for other types of illnesses. When clinical suspicion of myocarditis exists, chest-X ray and echocardiography are sufficient as screening tests. Cardiac troponins confirm the diagnosis in screened cases, with specificity of 100%.
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Affiliation(s)
- Hanaa Ibrahim Rady
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Hanan Zekri
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Schumm J, Greulich S, Wagner A, Grün S, Ong P, Bentz K, Klingel K, Kandolf R, Bruder O, Schneider S, Sechtem U, Mahrholdt H. Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis. J Cardiovasc Magn Reson 2014; 16:14. [PMID: 24461053 PMCID: PMC3913958 DOI: 10.1186/1532-429x-16-14] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/09/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The diagnosis of myocarditis is challenging due to its varying clinical presentation. Since myocarditis can be associated with significant 5-year mortality, and postmortem data show myocarditis in almost 10% of all adults suffering sudden cardiac death, individual risk stratification for patients with suspected myocarditis is of great clinical interest. We sought to demonstrate that patients with clinically suspected myocarditis and a normal cardiovascular magnetic resonance (CMR) according to our definition have a good prognosis, independent of their clinical symptoms and other findings. METHODS Prospective clinical long-term follow-up of consecutive patients undergoing CMR for work-up of clinically suspected myocarditis at our institution in 2007-2008. RESULTS Follow-up was available for n=405 patients (all-comers, 54.8% inpatients, 38% outpatient referrals from cardiologists). Median follow-up time was 1591 days. CMR diagnosis was "myocarditis" in 28.8%, "normal" in 55.6% and "other pathology" in 15.6%. Normal CMR was defined as normal left ventricular (LV) volumes and normal left ventricular ejection fraction (LV-EF) in the absence of late Gadolinium Enhancement (LGE). The overall mortality was 3.2%. There were seven cardiac deaths during follow-up, in addition one aborted SCD and two patients had appropriate internal cardioverter defibrillator (ICD) shocks - all of these occurred in patients with abnormal CMR. Kaplan-Meier analysis with log-rank test showed significant difference for major adverse cardiac events (cardiac death, sudden cardiac death (SCD), ICD discharge, aborted SCD) between patients with normal and abnormal CMR (p=0.0003). CONCLUSION In our unselected population of consecutive patients referred for CMR work-up of clinically suspected myocarditis, patients with normal CMR have a good prognosis independent of their clinical symptoms and other findings.
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Affiliation(s)
- Julia Schumm
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Simon Greulich
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Anja Wagner
- Comprehensive Cardiology of Stamford and Greenwich, Stamford, CT, USA
| | - Stefan Grün
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Kerstin Bentz
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Karin Klingel
- Department of Molecular Pathology, University of Tübingen, Tübingen, Germany
| | - Reinhard Kandolf
- Department of Molecular Pathology, University of Tübingen, Tübingen, Germany
| | - Oliver Bruder
- Institut für Herzinfarktforschung Ruhr, Essen, Germany
| | | | - Udo Sechtem
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
| | - Heiko Mahrholdt
- Department of Cardiology, Robert Bosch Medical Center, Stuttgart, Germany
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Jain PK, Sharma AK, Agarwal N, Jain PK, Sengar NS, Agarwal N, Siddiqui MZ, Pawal P, Singh AK, Gaba RD. A prospective clinical study of myocarditis in cases of acute ingestion of paraphenylene diamine (hair dye) poisoning in northern India. J Assoc Physicians India 2013; 61:633-644. [PMID: 24772701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Myocarditis is a unheard and unreported dangerous complication of hair dye ingestion which contains paraphenylene diamine. So a prospective study was planned to assess myocardial damage in regard to clinical profile and outcome with different treatment approaches in patients with oral ingestion of Hair dye. METHODS AND RESULTS The material comprised of 1595 cases admitted in Medicine Department of Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh-INDIA, from July 2004 to Jan 2011. Out of 1595 cases 1060 cases were of stone hair dye poisoning and 535 cases were of other branded hair dyes (powdered form containing less amount of Paraphenylene diamine). Diagnosis of myocarditis was made solely on the basis of the clinical signs/symptoms suggestive of myocardial damage, electrocardiography changes, elevated cardiac biomarkers and abnormalities on trans thoracic echocardiography. The cases were thoroughly studied for cardiac complications. Myocarditis was reported in 15% of total cases with mortality rate of 29%. Occurrence of myocarditis was directly related to amount of Hair dye ingested. In patients affected from myocarditis 9% develop life threatening Ventricular tachycardia/ventricular fibrillation. CONCLUSION Hair dye (Paraphenylene di amine) is highly toxic. In cases who consumed more than 10 gram of Paraphenylene diamine, myocarditis is a dangerous complication. Proper management includes continuous cardiac monitoring to prevent sudden cardiac death.
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Shauer A, Gotsman I, Keren A, Zwas DR, Hellman Y, Durst R, Admon D. Acute viral myocarditis: current concepts in diagnosis and treatment. Isr Med Assoc J 2013; 15:180-185. [PMID: 23662385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Acute myocarditis is one of the most challenging diseases to diagnose and treat in cardiology. The true incidence of the disease is unknown. Viral infection is the most common etiology. Modern techniques have improved the ability to diagnose specific viral pathogens in the myocardium. Currently, parvovirus B19 and adenoviruses are most frequently identified in endomyocardial biopsies. Most patients will recover without sequelae, but a subset of patients will progress to chronic inflammatory and dilated cardiomyopathy. The pathogenesis includes direct viral myocardial damage as well as autoimmune reaction against cardiac epitopes. The clinical manifestations of acute myocarditis vary widely--from asymptomatic changes on electrocardiogram to fulminant heart failure, arrhythmias and sudden cardiac death. Magnetic resonance imaging is emerging as an important tool for the diagnosis and follow-up of patients, and for guidance of endomyocardial biopsy. In the setting of acute myocarditis endomyocardial biopsy is required for the evaluation of patients with a clinical scenario suggestive of giant cell myocarditis and of those who deteriorate despite supportive treatment. Treatment of acute myocarditis is still mainly supportive, except for giant cell myocarditis where immunotherapy has been shown to improve survival. Immunotherapy and specific antiviral treatment have yet to demonstrate definitive clinical efficacy in ongoing clinical trials. This review will focus on the clinical manifestations, the diagnostic approach to the patient with clinically suspected acute myocarditis, and an evidence-based treatment strategy for the acute and chronic form of the disease.
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Affiliation(s)
- Ayelet Shauer
- Heart Failure and Heart Muscle Disease Center, Heart Institute, Hadassah University Hospital, Jerusalem, Israel
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Ghelani SJ, Spaeder MC, Pastor W, Spurney CF, Klugman D. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes 2012; 5:622-7. [PMID: 22828827 DOI: 10.1161/circoutcomes.112.965749] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is a lack of clear diagnostic and management guidelines for acute myocarditis in the pediatric population. We used a multi-institutional database to characterize demographics, practice variability, and outcomes in this population. METHODS AND RESULTS Patients with acute myocarditis (n=514) were identified from April 2006 to March 2011 using the Pediatric Health Information System database, and regional variations in management and outcomes were analyzed. Ninety-seven patients (18.9%) received extracorporeal membrane oxygenation, 22 (4.3%) received ventricular assist device, 21 (4.1%) received heart transplantation, and 37 (7.2%) died. Of the 104 patients who received extracorporeal membrane oxygenation or ventricular assist device, 17 (16.3%) had heart transplantation, 25 (24%) died, and 62 (59.6%) showed recovery of myocardial function. There was a decrease in the use of endomyocardial biopsy (P=0.03) and an increase in the use of magnetic resonance imaging (P<0.01) over the study period. Although the use of medications and procedures varied between different regions, the occurrence of death or heart transplantation showed no significant regional associations. The use of extracorporeal membrane oxygenation (odds ratio, 5.8; 95% confidence interval, 2.9-11.4; P<0.01), ventricular assist device (odds ratio, 8.2; 95% confidence interval, 2.7-24.9; P<0.01), and vasoactive medications (odds ratio, 5.7; 95% confidence interval, 1.2-26.1; P=0.03) was independently associated with death/transplantation. CONCLUSIONS There is significant temporal and regional variation in the diagnostic modalities and management used for pediatric myocarditis, which continues to have high morbidity and mortality. Extracorporeal membrane oxygenation, ventricular assist device, and vasoactive medications are independently associated with increased mortality/transplantation.
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Affiliation(s)
- Sunil J Ghelani
- Division of Cardiology, Division of Critical Care Medicine, and Clinical Data Operations, Children's National Medical Center, Washington, DC 20010, USA
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Abstract
Leptospirosis is a neglected global disease with significant morbidity and mortality. Cardiac complications such as chest pain, arrhythmias, pulmonary oedema and refractory shock have been reported in patients with severe disease. However, the frequency and extent of cardiac involvement in leptospirosis, are under-reported and poorly understood. Multiple factors may contribute to clinical manifestations that suggest cardiac involvement, causing diagnostic confusion. A variety of electrocardiographic changes occur in leptospirosis, with atrial fibrillation, atrioventricular conduction blocks and non-specific ventricular repolarization abnormalities being the most common. Electrolyte abnormalities are likely to contribute to electrocardiographic changes; direct effects on Na(+)-K(+)-Cl(-) transporters in the renal tubules have been postulated. Echocardiographic evidence of myocardial dysfunction has not been adequately demonstrated. The diagnostic value of cardiac biomarkers is unknown. Histopathological changes in the myocardium have been clearly shown, with myocardial inflammation and vasculitis present in postmortem studies. Nonetheless, the pathophysiology of cardiac involvement in leptospirosis is poorly understood. Cardiac involvement, demonstrated electrocardiographically or clinically, tends to predict poor outcome. No specific therapies are available to prevent or treat cardiac involvement in leptospirosis; current management is based on correction of deranged homeostasis and supportive therapy. Evidence suggests that direct myocardial damage occurs in patients with severe leptospirosis, and further studies are recommended to elucidate its pathophysiology, clinical features and contribution to overall prognosis, and to identify appropriate diagnostic investigations and specific therapies.
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Zhang CH, Shen D, Sun HY, Zhang LW, Ma YJ, Huang DS. [Prognostic value of brain natriuretic peptide in people with viral myocarditis]. Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za Zhi 2012; 26:125-126. [PMID: 23002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To explore the brain natriuretic peptide (BNP) on prognostic value in patients with viral myocarditis. METHODS A total of 48 patients with viral myocarditis and 42 healthy people were enrolled and followed up for two years. The NYHA class and LVEF were recorded and the concentration of BNP were measured. RESULTS The concentration of BNP were higher and EF were lower in patients with viral myocarditis (P < 0.01) than contrast people. Higher levels of plasma BNP were related to higher mortality. CONCLUSION Levels of brain natriuretic peptide measured in the plasma could be a useful biochemical marker for the myocarditis, and high concentration of BNP may correlate with poor prognosis in patients with myocarditis.
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Affiliation(s)
- Chun-Hong Zhang
- Cardiovascular Department of First Affiliated Hospital to PLA General Hospital, Beijing 100048, China.
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Yun SH, Lee WG, Kim YC, Ju ES, Lim BK, Choi JO, Kim DK, Jeon ES. Antiviral activity of coxsackievirus B3 3C protease inhibitor in experimental murine myocarditis. J Infect Dis 2012; 205:491-7. [PMID: 22207647 DOI: 10.1093/infdis/jir745] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
BACKGROUND We investigated the efficacy of a 3C protease inhibitor (3CPI) in a murine coxsackievirus B3 (CVB3) myocarditis model. CVB3 is a primary cause of viral myocarditis. The CVB3 genome encodes a single polyprotein that undergoes a series of proteolytic events to produce several viral proteins. Most of this proteolysis is catalyzed by the 3C protease (3CP). METHODS AND RESULTS By way of a micro-osmotic pump, each mouse received 50 mM 3CPI in 100 μL of 100% dimethyl sulfoxide (DMSO) during a 72-hour period. On the day of pump implantation, mice (n = 40) were infected intraperitoneally with 10(6) plaque-forming units of CVB3. For the infected controls (n = 50), the pump was filled with 100% DMSO without 3CPI. The 3-week survival rate of 3CPI-treated mice was significantly higher than that of controls (90% vs 22%; P < .01). Myocardial inflammation, viral titers, and viral RNA levels were also reduced significantly in the 3CPI-treated group compared with these measures in the controls. CONCLUSIONS The protein-based drug 3CPI inhibited the activity of 3CP of CVB3, significantly inhibited viral proliferation, and attenuated myocardial inflammations, subsequent fibrosis, and CVB3-induced mortality in vivo. Thus, this CVB3 3CPI has the potential to be a novel therapeutic agent for the treatment of acute viral myocarditis during the viremic phase.
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Affiliation(s)
- Soo-Hyeon Yun
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
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Al-Biltagi M, Issa M, Hagar HA, Abdel-Hafez M, Aziz NA. Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis. Acta Paediatr 2010; 99:1510-6. [PMID: 20491698 DOI: 10.1111/j.1651-2227.2010.01882.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To study the correlation between cardiac troponins blood levels and degrees of cardiac dysfunction in children with acute and fulminant viral myocarditis and to study their prognostic role in predicting the outcomes and risk of having dilated cardiomyopathy. METHODOLOGY Troponin I & T blood levels were measured in 65 children with acute or fulminant viral myocarditis. The cardiac functions of RV & LV were assessed by Doppler echocardiography. RESULTS The levels of cTnI & CTnT were significantly higher in patients with fulminant myocarditis than in controls and children with acute myocarditis (p < 0.05 & <0.001* respectively). The cardiac functions were significantly impaired in fulminant myocarditis than in acute myocarditis (p < 0.001*). There were negative correlations between the cardiac troponins levels and the cardiac functions measured by echocardiography in children with acute and fulminant myocarditis. There were 3 deaths (7.5%), and 10 (25%) children developed dilated cardiomyopathy in acute myocarditis while there were eight deaths (32%) and one patient (4%) who developed dilated cardiomyopathy in fulminant myocarditis group. CONCLUSION Cardiac troponins levels can predict the severity of myocarditis and the prognosis on the short-term level. Fulminant myocarditis was associated with higher levels of both cTn I & cTn T than acute myocarditis. Despite that fulminant myocarditis has a more aggressive course, the risk of developing cardiomyopathy was less than in acute myocarditis.
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Machado S, Roubille F, Gahide G, Vernhet-Kovacsik H, Cornillet L, Cung TT, Sportouch-Dukhan C, Raczka F, Pasquié JL, Gervasoni R, Macia JC, Cransac F, Davy JM, Piot C, Leclercq F. Can troponin elevation predict worse prognosis in patients with acute pericarditis? Ann Cardiol Angeiol (Paris) 2010; 59:1-7. [PMID: 19963205 DOI: 10.1016/j.ancard.2009.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 07/15/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers. PATIENTS AND METHODS Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation. RESULTS Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p=0.01), ST-segment elevation (nine patients between 14; p=0.03), higher troponin I (7.3 microg/L [95% CI 4.4-10.2]; p<10(-4)) and lower systemic inflammation (CRP peak 38.1mg/L [95% CI 7-69.2]; p=0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p=0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p=0.01). Follow-up showed no difference in terms of functional status (p=0.3) and global complications (p=0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p=0.04). MRI follow-up showed myocardial sequelae without clinical impact. CONCLUSION Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.
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Affiliation(s)
- S Machado
- Département de cardiologie, CHU Arnaud-de-Villeneuve, 371 avenue du Doyen-Gaston-Giraud, Montpellier, France
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Cohen D. [Reaction on 'Myocarditis and cardiomyopathy underestimated complications resulting from clozapine therapy']. Tijdschr Psychiatr 2010; 52:727-729. [PMID: 20931487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
Myocarditis, an inflammatory disease of heart muscle, is an important cause of dilated cardiomyopathy worldwide. Viral infection is also an important cause of myocarditis, and the spectrum of viruses known to cause myocarditis has changed in the past 2 decades. Several new diagnostic methods, such as cardiac magnetic resonance imaging, are useful for diagnosing myocarditis. Endomyocardial biopsy may be used for patients with acute dilated cardiomyopathy associated with hemodynamic compromise, those with life-threatening arrhythmia, and those whose condition does not respond to conventional supportive therapy. Important prognostic variables include the degree of left and right ventricular dysfunction, heart block, and specific histopathological forms of myocarditis. We review diagnostic and therapeutic strategies for the treatment of viral myocarditis. English-language publications in PubMed and references from relevant articles published between January 1, 1985, and August 5, 2008, were analyzed. Main keywords searched were myocarditis, dilated cardiomyopathy, endomyocardial biopsy, cardiac magnetic resonance imaging, and immunotherapy.
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Affiliation(s)
| | | | - Leslie T. Cooper
- Individual reprints of this article are not available. Address correspondence to Leslie T. Cooper Jr, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ().
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Alne H, Thomassen MS, Takle H, Terjesen BF, Grammes F, Oehme M, Refstie S, Sigholt T, Berge RK, Rørvik KA. Increased survival by feeding tetradecylthioacetic acid during a natural outbreak of heart and skeletal muscle inflammation in S0 Atlantic salmon, Salmo salar L. J Fish Dis 2009; 32:953-961. [PMID: 19602091 DOI: 10.1111/j.1365-2761.2009.01078.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We have previously documented increased survival by feeding tetradecylthioacetic acid (TTA) during a natural outbreak of infectious pancreatic necrosis in post-smolt S1 Atlantic salmon. The aim of the present study was to test the effects of dietary TTA in S0 smolt at a location where fish often experience natural outbreaks of heart and skeletal muscle inflammation (HSMI) during their first spring at sea. The experimental groups were fed a diet supplemented with 0.25% TTA for a 6-week period prior to a natural outbreak of HSMI in May 2007. Relative percent survival for the groups fed TTA was 45% compared with control diets, reducing mortality from 4.7% to 2.5%. Expression of genes related to lipid oxidation was higher in cardiac ventricles from salmon fed TTA compared with controls. In addition, salmon fed TTA had periodically reduced levels of plasma urea, and increased cardiosomatic index and growth. Reduced mortality and increased growth after administration of TTA may be related to a combination of anti-inflammatory effects, and an altered metabolic balance with better protein conservation because of increased lipid degradation.
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Bobin AN, Parkhomenko IG. [Complications of typhoid fever and its causes in an epidemic focus]. Arkh Patol 2009; 71:46-50. [PMID: 19938704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Autopsy records, case histories, and archival organ and tissue samples were studied in 109 Soviet military men during the Afghanistan war, who had died of typhoid fever in 1980-1986. Morphological and statistical studies demonstrated that the current pattern and frequency of complications and immediate causes of death with the epidemic incidence in the endemic focus largely corresponded to those in the preantibiotic period. The specific features were the higher rate and early development of enteric complications, infectious myocarditis, and infectious-toxic shock, the higher, as compared with the past years, proportion of deaths from circulatory diseases and a reduction of cases of total intoxication. Acute cardiovascular insufficiency associated with infectious myocarditis and infectious-toxic shock was one of the main causes of death in the first 2 weeks of typhoid fever. Most patients died of perforative peritonitis and pneumonia in the later period.
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van der Meulen M, van Doornum GJJ, Corel LJA, Dalinghaus M, Fraaij PLA, de Hoog M. [Acute myocarditis due to Coxsackie virus B3 in two infants]. Ned Tijdschr Geneeskd 2009; 153:A152. [PMID: 19785892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In the spring and summer of 2008 two seriously ill male infants were admitted to a paediatric intensive care unit. Initially, both had a fever, were drinking less and were pale complexioned. Physical examination revealed tachycardia, slow capillary filling and liver enlargement. Within a few hours, both infants developed circulatory and respiratory failure. A chest radiograph showed that the heart was enlarged and echocardiography revealed that the pump function of both ventricles was severely diminished. Myocarditis caused by Coxsackie virus B3 was diagnosed when the virus was demonstrated in serum and faeces. At the last follow-up, one infant still had severe pump function disorders, and the other one died. Coxsackie virus B3 is a non-polio enterovirus that usually causes mild clinical syndromes but is also associated with myocarditis and overwhelming, systemic neonatal infections. In neonates with mild symptoms one should be alert to progression to circulatory insufficiency, especially if the mother experiences a flu-like illness in the perinatal period. Early recognition of heart failure and adequate diagnostic testing for cardiotropic viruses is important as morbidity and mortality is considerable.
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Savón C, Acosta B, Valdés O, Goyenechea A, Gonzalez G, Piñón A, Más P, Rosario D, Capó V, Kourí V, Martínez PA, Marchena JJ, González G, Rodriguez H, Guzmán MG. A myocarditis outbreak with fatal cases associated with adenovirus subgenera C among children from Havana City in 2005. J Clin Virol 2008; 43:152-7. [PMID: 18657472 DOI: 10.1016/j.jcv.2008.05.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/01/2008] [Accepted: 05/09/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among multiple causes of acute myocarditis, viral infection, especially that due to enteroviruses and adenoviruses, is the leading cause. In the summer 2005 an outbreak of a febrile syndrome accompanied by acute cardiac decompensation occurred in infants and young children in Havana City. Eleven patients had a rapid evolution of disease and there were 8 fatalities from cardiac failure secondary to myocarditis. OBJECTIVE The aim of the present study was to determine the etiological agent responsible for this outbreak. STUDY DESIGN Children admitted to the pediatric hospitals of Havana City from July 3 to August 2 with this clinical presentation were studied. Forty samples of necropsy tissue, cerebrospinal fluid, stools and serum were tested by molecular methods for 14 respiratory viruses, 6 herpesviruses and generic enteroviruses and flavirus and alfaviruses. Viral isolation was performed in A-549 cells. Isolated viruses were typed by sequence analysis. RESULTS Adenovirus genome was detected in 6 of the 8 fatal cases-the lungs in 5 (63%) and the myocardium in 3 (37%). In two fatal cases, viral genome was detected in both lung and myocardium. Adenovirus was isolated in five fatal cases. In all three non-fatal cases, adenovirus genome was detected and adenovirus was isolated into two. Sequence analysis showed that adenovirus type 5 was the only isolate from fatal cases and adenovirus 1 the only isolate in non-fatal cases. No other viruses were found by PCR or isolation techniques. CONCLUSION Adenovirus was the etiologic agent implicated in this myocarditis outbreak and adenovirus type 5 was associated with fatal outcome.
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Affiliation(s)
- Clara Savón
- Tropical Medicine Institute Pedro Kourí, Havana, Cuba.
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Abstract
Forensic experts are often required to give an opinion on the cause of death and its medico-legal interpretation in cases where an individual dies after receiving non-fatal injuries and at autopsy is discovered to have had a natural disease that alone could have caused death. The significance of this varies in different countries depending on the local laws relating to death in cases of trivial trauma associated with natural disease. This paper discusses this issue from an Indian perspective with the help of an illustrative case report and highlights the importance of the forensic pathologist in such cases.
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Affiliation(s)
- Anil Kohli
- Department of Forensic Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi-110095, India.
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