Presentation Of Acute Myocarditis Research Articles

Rationale and design of the French cohort of acute myocarditis diagnosed by cardiac magnetic resonance imaging (MyocarditIRM)

BackgroundAcute myocarditis usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favourable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders, and is considered the leading cause of sudden cardiac death in young, apparently healthy, adults. There are no specific recommendations for acute myocarditis diagnosis and management, only expert consensus, given the lack of large databases. AimThe main objective is to describe the contemporary presentation of acute myocarditis, its management and in-hospital outcomes. Secondary objectives are to investigate survival and event-free survival for up to 10years of follow-up, the determinants of prognosis, the modalities of treatment and follow-up and the gaps between expert consensus and real-life management. MethodsMyocarditIRM is a prospective multicentre cohort that enrolled 803 consecutive patients with acute myocarditis in 49 participating centres in France between 01 May 2016 and 28 February 2019. The diagnosis of acute myocarditis was acknowledged by cardiac magnetic resonance, using the Lake Louise Criteria. Exclusion criteria were age<18years, lack of health coverage, contraindication to cardiac magnetic resonance and refusal to participate. Detailed information was collected prospectively, starting at admission. Cardiac magnetic resonance imaging (diagnosis and follow-up) is analysed centrally by the certified core laboratory IHU ICAN. Ten years of follow-up for each patient is ensured by linking with the French National Health Database, and includes information on death, hospital admissions, major clinical events and drug consumption. ConclusionThis prospective cohort with long-term follow-up represents the largest database on acute myocarditis worldwide, and will improve knowledge about its presentation, management and outcomes.

A rare presentation of acute myocarditis as a manifestation of adult-onset Still’s disease: a case report

Abstract Background Adult-onset Still’s disease (AOSD) is a rare systemic autoinflammatory condition characterized by a classical triad of symptoms that include prolonged fever, polyarthritis, and a characteristic salmon-pink skin rash. It can affect a variety of organ systems resulting in many different clinical presentations and is usually a diagnosis of exclusion. Myocarditis complicated by cardiogenic shock is a rare and life-threatening manifestation of AOSD, typically affecting younger patients. There is a limited experience and evidence in how best to manage this challenging patient cohort. Case summary A previously fit and well 22-year-old male presented with fever, arthralgia, and general malaise. On clinical examination, he was pyrexial and hypotensive, requiring vasopressor support for presumed septic shock. Subsequent transthoracic echocardiography and cardiac MRI findings were in keeping with fulminant myocarditis. Further septic and auto-immune screens were negative although he responded well to high-dose intravenous corticosteroids. Attempts to wean immunosuppression were unsuccessful, and his ferritin was markedly elevated (20 233 μg/L). A diagnosis of AOSD was suspected after exclusion of other possible causes. The successful addition of tocilizumab (an interleukin-6 receptor antagonist) therapy allowed for gradual de-escalation of steroid therapy and disease remission, with on-going remission at 18 months on maintenance therapy. Discussion This case highlights the importance of considering AOSD as a rare cause for myocarditis, especially when fever is present, or disease is severe. Failure to improve with first-line therapy involving high-dose corticosteroids, or inability to wean that therapy, should prompt consideration for escalation of therapy, with tocilizumab seemingly an effective treatment option.

Infarct-like versus Non-Infarct-like Clinical Presentation of Acute Myocarditis: Comparison of Cardiac Magnetic Resonance (CMR) Findings.

The clinical presentation of acute myocarditis (AM) is widely variable, ranging from a subclinical disease to an infarct-like syndrome. Cardiac magnetic resonance (CMR) has become the reference non-invasive diagnostic tool for suspected AM, allowing the identification of the various hallmarks of myocardial inflammation (edema, fibrosis, and hyperemia). The aim of the study was to investigate any differences in morphological, functional, and tissue characterization CMR parameters between infarct-like AM in patients with unobstructed coronary arteries and non-infarct-like AM, diagnosed according to the original Lake-Louise Criteria (LLC); Methods: We retrospectively selected 39 patients diagnosed with AM according to LLC, divided into 2 groups according to the clinical presentation: infarct-like in group 1 patients and non-infarct-like in group 2 patients. CMR morphologic, functional, and tissue characterization parameters were analyzed and compared. In group 1, CMR tissue characterization parameters were mainly altereda in septal location with mesocardial myocardial involvement; in group 2, CMR tissue characterization parameters were mainly altered in a lateral location with subepicardial myocardial involvement mainly at the mid-cavity. No significant differences in morphological or functional parameters were observed between the two study groups. Our results showed differences in the localization and distribution of myocardial tissue damage assessed by CMR among forms of AM accompanied by an infarct-like clinical presentation compared with non-infarct-like presentations of AM. The mechanisms underlying the different preferential sites of damage observed in our study are not known, and we do not exclude the possibility of their prognostic implications.

PO-01-087 A RARE CASE OF BI-ATRIAL FDG-UPTAKE: PRESENTING AS NEW ONSET ATRIAL FIBRILLATION

Isolated atrial myocarditis is rare, with presenting symptoms that are non-specific. Prior reports have suggested association with atrial arrythmias and increased risk of stroke due to atrial dysfunction. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) CT scan is considered as a goal standard test for the diagnosis of myocarditis. To present a case highlighting that isolated atrial myocarditis had higher incidence atrial arrythmias and oral anticoagulation should be considered in such cases. N/A A 55yo male with no prior medical history presented with non-specific symptoms of fatigue, shortness of breath and frequent palpitations. He underwent 2D echocardiogram showed LVEF of 50-55% with mild bi-atrial dilatation with no regional wall motion abnormalities and was diagnosed with incidental atrial fibrillation during the procedure. He was referred to cardiac electrophysiology for further work up. During his initial EP clinic visit, 12 lead ECG demonstrated normal sinus rhythm with premature atrial contractions and premature ventricular contractions. Due to symptomatic, dual chamber arrythmias, cardiac MRI (CMR) and FDG-PET CT was ordered to rule out myocarditis. The CMR was negative for any LGE however, high-fat dietary preparation FDG-PET CT scan revealed uptake on bi-atrial walls (figure) and interatrial septum with SUV max of 3.1. There was no LV myocardial FDG uptake noted. Patient was diagnosed with isolated atrial myocarditis and was started on dronedarone, OAC (CHADS2VASc =0) for stroke prophylaxis and immunosuppressive therapy (methotrexate and low dose prednisone). Invasive atrial myocardial biopsy was not considered due good response to therapy. Isolated atrial myocarditis is an uncommon presentation of acute myocarditis and is associated with atrial arrythmias. FDG PET-CT or CMR imaging may be useful to aid diagnosis. Long-term response to immunosuppressive therapy may need further investigations. OAC should be considered for stroke prophylaxis, despite low CHADS2VASc due to unknown long-term implications of atrial dysfunction.

106 A CASE OF COMPLETE ATRIOVENTRICULAR BLOCK AND ALTERNATING BUNDLE BRANCH BLOCK DUE TO FULMINANT MYOCARDITIS

Abstract A 41-year-old man, without previous cardiological history, presented at the emergency department with hypotension and multi-organ failure. Laboratory testing showed elevated white cell blood count (16780/mcL; normal value 4000-11000/mcL; 90% neutrophils), high-sensibility troponin I (23247 ng/L; normal value &amp;lt;18 ng/L) and NT-pro-BNP (21914 pg/mL; normal value &amp;lt;300 pg/mL). At electrocardiogram (EKG) there was sinus rhythm with complete atrioventricular block and alternating right and left bundle branch block. Echocardiography revealed a moderate left ventricular (LV) dilatation, mild LV hypertrophy, severe biventricular dysfunction (LV Ejection Fraction - EF - 30%) with dense spontaneous echo contrast and moderate pulmonary hypertension (systolic pulmonary artery pressure 51 mmHg). After positioning a temporary pacemaker, the patient was transferred to our Cardiac Intensive Care Unit. After initial hemodynamic stabilization with endovenous inotropes, diuretics, and mechanical circulatory support (intra-aortic balloon pump), coronary angiography was performed showing normal coronary arteries. Since fulminant myocarditis was suspected and magnetic resonance was not feasible due to the patient's instability, an endomyocardial biopsy (EMB) was performed with the evidence of myocardial edema, initial myocardial fibrosis, and the concomitant presence of lymphocytic and eosinophilic endo-myocarditis (despite normal eosinophilic blood count) without evidence of active viral replication. After careful exclusion of latent or active infections, high doses of corticosteroids and azathioprine were initiated, with rapid laboratoristic and clinical response. EKG showed AV block regression and QRS width's normalization, so the pacemaker was removed. LVEF rapidly improved and was completely normalized at discharge after two weeks. In the early follow-up, a cardiac magnetic resonance (CMR) was performed with evidence of persistency of mildly dilated LV, normalization of LV wall thickness and biventricular function, a diffuse increase of T1 relaxation time, increased T2 signal of the anterior and septal walls, and intramural anteroseptal late gadolinium enhancement (LGE). Fulminant myocarditis is a rare presentation of acute myocarditis, with low incidence but high mortality. The inflammation of the myocardium itself leads to acute heart failure, cardiogenic shock, and cardiac arrhythmias, including sinus arrest, AV block, ventricular tachycardia, and ventricular fibrillation during the acute phase. In our case, AV block could be an expression of anteroseptal involvement, documented at CMR. This localization has already been associated with worse clinical presentation and could be a marker of poor prognosis. Diagnosis and treatment of fulminant myocarditis require EMB, to obtain information about the etiology and active viral replication in the heart tissue. In our case, the florid inflammatory state and the absence of viral replication allowed prompt treatment with immunosuppressors, with a quick and full recovery of biventricular function in only two weeks.

Comparing the findings and diagnostic accuracy of cardiac magnetic resonance imaging in patients with biopsy confirmed acute myocarditis presenting with infarct-like and heart failure symptoms

Abstract Introduction Cardiac magnetic resonance imaging (CMR) is considered the reference imaging modality in providing a non-invasive diagnosis of acute myocarditis (AM), as it allows for the detection of myocardial injury associated with AM. However, the diagnostic accuracy and pattern of CMR findings appear to differ according to clinical presentation. Methods This is a retrospective cross-sectional study. Consecutive adult patients presenting to a single tertiary centre in South Africa between August 2017 and November 2021 with endomyocardial biopsy (EMB) confirmed AM presenting with infarct-like (IL) or heart failure (HF) symptoms who had undergone CMR were included. Results Thirty-eight patients were enrolled. Twenty-two presented with IL symptoms and sixteen with HF symptoms. On CMR, the IL group had significantly higher ejection fractions of both ventricles (LVEF 54.3±14.9% vs 35.4±14.0%, p&amp;lt;0.001; RVEF 56.8±10.9% vs 43.6±18.6%, p=0.03), despite similar end diastolic dimensions (LVEDVi 83.2±30.9 ml/m2 vs 104.4±38.0 ml/m2, p=0.07; RVEDVi 74.4±22.1 ml/m2 vs 85.8±29.9 ml/m2, 0=0.19). Myocardial oedema was detected more frequently on T2-weighted imaging (90.9% vs 62.5%, p=0.05) and in more myocardial segments (3.0 (IQR 2.0–4.0) vs 1.0 (IQR 0–1.0), p 0.003) in the IL group. Despite no significant difference in the prevalence of late gadolinium enhancement (LGE) between the two groups (95.5% vs 68.8%, p=0.06), the IL group had LGE detectable in significantly more ventricular segments (4.5 (IQR 2.3–6.0) vs 2.0 (IQR 0–3.3), p=0.01) and in a different distribution. The sensitivity of the original Lake Louise Criteria (LLC) was 90.9% in IL patients and 56.3% in HF patients, which improved to 95.5% and 68.8% with the updated LLC respectively. Conclusion The pattern of CMR findings and its diagnostic accuracy appears to differ in AM patients presenting with IL and HF symptoms. Although the sensitivity of the LLC improved with the addition of parametric mapping in the HF group, it remained lower than that of the IL group, and suggests that EMB should be strongly considered in patients with clinically suspected AM presenting with HF. Funding Acknowledgement Type of funding sources: None.

Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF.

Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization. Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF. Data of patients undergoing cardiac magnetic resonance (CMR) for clinically suspected AM in seven European Centres (2013-2020) were retrospectively analysed. Patients with AM confirmed by CMR and LVEF ≥50% were included. LGE was visually characterized: localized versus. non-localized, subepicardial versus midwall. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including cardiac death, life-threatening arrhythmias, development of heart failure or of LVEF <50%. Of 389 screened patients, 256 (66%) fulfilled inclusion criteria: median age 36 years, 71% males, median LVEF 60%, median LV-GLS -17.3%. CMR was performed at 4 days from hospitalization. At 27 months, 24 (9%) patients experienced ≥1 ACE (71% developed LVEF <50%). Compared to the others, they had lower median LV-GLS values (-13.9% vs. -17.5%, p=.001). At Kaplan-Meier analysis, impaired LV-GLS (both considered as > -20% or quartiles), non-localized and midwall LGE were associated with ACEs. Patients with LV-GLS ≤-20% did not experience ACEs. LV-GLS remained associated with ACEs after adjustment for non-localized and midwall LGE. In AM presenting with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE characterization, improving risk stratification and representing a rationale for further studies of therapy in this cohort.

Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

Abstract Funding Acknowledgements Type of funding sources: None. Background Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization (1). Purpose Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF (2,3). Methods Data of patients undergoing cardiac magnetic resonance (CMR) for clinically suspected AM in seven European Centres (2013-2020) were retrospectively analysed. Patients with AM confirmed by CMR and LVEF ≥50% were included. LGE was visually characterized: localized vs. diffuse, subepicardial vs midwall. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including cardiac death, life-threatening arrhythmias, development of heart failure or of LVEF &amp;lt;50%. Results Of 389 screened patients, 256 (66%) fulfilled inclusion criteria: median age 36 years, 71% males, median LVEF 60%, median LV-GLS -17.3%. CMR was performed at 4 [2-12] days from hospitalization. At 27 months, 24 (9%) patients experienced ≥1 ACE (71% developed LVEF &amp;lt;50%). Compared to the others, patients experiencing ACEs had lower median LV-GLS values (-13.9% vs -17.5%, p=0.001). At Kaplan-Meier analysis, impaired LV-GLS (both considered as &amp;gt;-20% or quartiles), diffuse and midwall LGE were associated with ACEs (Figure 1). Patients with LV-GLS ≤-20% did not experience ACEs. LV-GLS remained associated with ACEs after adjustment for diffuse and midwall LGE. Conclusions In AM presenting with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE characterization, improving risk stratification and representing a rationale for further studies of therapy in this cohort (Figure 2).

Comparing the findings and diagnostic sensitivity of cardiovascular magnetic resonance in biopsy confirmed acute myocarditis with infarct-like vs. heart failure presentation

BackgroundCardiovascular magnetic resonance (CMR) is considered the reference imaging modality in providing a non-invasive diagnosis of acute myocarditis (AM), as it allows for the detection of myocardial injury associated with AM. However, the diagnostic sensitivity and pattern of CMR findings appear to differ according to clinical presentation.MethodsThis is a retrospective cross-sectional study. Consecutive adult patients presenting to a single tertiary centre in South Africa between August 2017 and January 2022 with AM confirmed on endomyocardial biopsy (EMB) were enrolled. Patients with infarct-like symptoms, defined as those presenting primarily with chest pain syndrome with associated ST-T wave changes on electrocardiogram, or heart failure (HF) symptoms, defined as clinical signs and symptoms of HF without significant chest discomfort, were compared using contrasted CMR and parametric techniques with EMB confirmation of AM as diagnostic gold standard.ResultsForty-one patients were identified including 23 (56%) with infarct-like symptoms and 18 (44%) with HF symptoms. On CMR, the infarct-like group had significantly higher ejection fractions of both ventricles (LVEF 55.3 ± 15.3% vs. 34.4 ± 13.5%, p < 0.001; RVEF 57.3 ± 10.9% vs. 42.9 ± 18.2%, p = 0.008), without significant differences in end diastolic volumes (LVEDVI 82.7 ± 30.3 ml/m2 vs. 103.4 ± 35.9 ml/m2, p = 0.06; RVEDVI 73.7 ± 22.1 ml/m2 vs. 83.9 ± 29.9 ml/m2, p = 0.25). Myocardial oedema was detected more frequently on T2-weighted imaging (91.3% vs. 61.1%, p = 0.03) and in more myocardial segments [3.0 (IQR 2.0–4.0) vs. 1.0 (IQR 0–1.0), p = 0.003] in the infarct-like group. Despite the absence of a significant statistical difference in the prevalence of late gadolinium enhancement (LGE) between the two groups (95.7% vs. 72.2%, p = 0.07), the infarct-like group had LGE detectable in significantly more ventricular segments [4.5 (IQR 2.3–6.0) vs. 2.0 (IQR 0–3.3), p = 0.02] and in a different distribution. The sensitivity of the original Lake Louise Criteria (LLC) was 91.3% in infarct-like patients and 55.6% in HF patients. When the updated LLC, which included the use of parametric myocardial mapping techniques, were applied, the sensitivity improved to 95.7% and 72.2% respectively.ConclusionThe pattern of CMR findings and its diagnostic sensitivity appears to differ in AM patients presenting with infarct-like and HF symptoms. Although the sensitivity of the LLC improved with the addition of parametric mapping in the HF group, it remained lower than that of the infarct-like group, and suggests that EMB should be considered earlier in the course of patients with clinically suspected AM presenting with HF.

100 Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

Abstract Aims Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular (LV) ejection fraction (EF) relies mostly on late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) imaging. In this specific AM population, LV peak global longitudinal strain (LV-GLS) measured by feature tracking (FT) analysis might provide further prognostic information. Methods and results Data of patients undergoing CMR for clinically suspected AM in seven European Centres, between January 2013 and August 2020, were retrospectively analysed. Those patients fulfilling CMR Lake Louise Criteria (LLC) for the diagnosis of AM and presenting with normal LVEF (≥50%) were included. Patients presenting with heart failure (HF) or significant arrhythmic events, LVEF &amp;lt;50% or haemodynamic instability were excluded. CMR-LGE extent (localized vs. diffuse), localization (subepicardial vs. mid-wall), and distribution (anteroseptal vs. inferolateral) were visually assessed. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including a composite of cardiac death, development of heart failure, life-threatening arrhythmias, or development of LVEF &amp;lt;50%. In patients experiencing more than one event, the first one was considered for the outcome analysis. Of 389 patients with clinically suspected AM, 256 (66%) had confirmed AM with LVEF ≥50% and were included. Median age was 36 years, 71% were males, median LVEF was 60%, and median LV-GLS −17.3%. CMR was performed at a median time of 4 (IQR: 2–12) days from hospital admission. At a median follow-up of 27 months, 24 (9%) patients experienced at least one ACE with development of LVEF &amp;lt;50% accounting for 17 [71%]. Compared to the others, patients experiencing ACEs had lower median LV-GLS values at baseline (−13.9% vs. −17.5%, P = 0.001). At Kaplan–Meier analysis, impaired LV-GLS (both considered as &amp;gt;-20% or quartiles), diffuse and mid-wall LGE were associated with a significantly higher rate of ACEs. LV-GLS remained independently associated with ACEs after adjustment for diffuse or mid-wall LGE as covariate at bivariable analysis. Conclusions In AM with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE, improving risk stratification and providing a rationale for further studies of therapy in this cohort. 100 Figure

Abstract 15512: Predictors of Normalization of Left Ventricular Systolic Function After Acute Myocarditis -multicenter Observational Study

Introduction: The clinical presentation of acute myocarditis is highly variable, and its prognosis is occasionally unpredictable. Even the patients discharge alive, left ventricular (LV) remodeling occurs during the follow-up period in some cases, which causes the progression of dilated cardiomyopathy or sudden cardiac death. Purpose: We aimed to investigate the predictors of the recovery of LV ejection fraction (LVEF) in patients with acute myocarditis. Methods: This multicenter observational study included 20 patients [average age 38 years, 18 (90%) male] suffering acute myocarditis who were urgently hospitalized between 2007 and 2019. Enrolled patients were assigned into 2 groups depending on a recovery of LV function that was defined as LVEF ≥55% by transthoracic echocardiography (TTE) within 12 months after the onset; the Recovery group (n=8) and Non-recovery group (n=12). Results: Overall, LVEF increased from 37% to 52% (p&lt;0.001) during the follow-up period (median interval: 180 (IQR: 42-332) days). There was no statistically differences in baseline clinical profiles or medications at discharge between the groups. However, LVEF at admission was significantly higher in the Recovery group than Non-recovery group (47±13% vs. 31±13%, p=0.014). The univariate logistic regression analysis showed that baseline LVEF was related to a recovery of LV function (odds ratio, 1.12; 95% confidence interval, 1.00-1.26). The ROC curve for a recovery of LV function revealed that the cut-off value of LVEF at admission was 42% (sensitivity: 75%, specificity: 83%, area under the curve: 0.83, Figure A ). Patients with baseline LVEF ≥42% achieved significantly higher rates of LV functional recovery after acute myocarditis than those with LVEF &lt;42% (17% vs 75%, p=0.019, Figure B ). Conclusions: Baseline LVEF could predict a normalization of LV function in patients with acute myocarditis. Close observation and TTE follow-up should be considered in such a refractory population.

Quantifying and reporting cardiac findings in imaging of COVID-19 patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection continues to be a public health emergency and a pandemic of international concern. As of April 31st, the reported cases of COVID-19 are three million in 186 countries. Reported case fatality has crossed 200 thousand among which more than fifty thousand has been in the USA. Most patients present with symptoms of fever, cough, and shortness of breath following exposure to other COVID-19 patients. Respiratory manifestations predominate in patients with mild, moderate, severe illness. Imaging of patients with COVID-19 consistently reports various pulmonary parenchymal involvement. In this article we wanted to reinforce and review the various reported imaging patterns of cardiac and mediastinal involvement in COVID-19 patients. Among patients with COVID 19 who underwent various imaging of chest various cardiac findings including pericardial effusion, myocarditis, cardiomegaly has been reported. Most of these findings have been consistently reported in patients with significant acute myocardial injury, and fulminant myocarditis. Acute biventricular dysfunction has also been reported with subsequent improvement of the same following clinical improvement. Details of cardiac MRI is rather limited. In a patient with clinical presentation of acute myocarditis, biventricular myocardial interstitial edema, diffuse biventricular hypokinesia, increased ventricular wall thickness, and severe LV dysfunction has been reported. Among patients with significant clinical improvement in LV structure and function has also been documented. With increasing number of clinical cases, future imaging studies will be instrumental in identifying the various cardiac manifestations, and their relation to clinical outcome.

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Abstract Background Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart. Aims Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms. Methods 113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression. Results A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p&amp;lt;0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p&amp;lt;0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis. Conclusion Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar. Strain, LGE in acute phase and follow-up Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Use of SARS-CoV-2-infected deceased organ donors: Should we always "just say no?"

In the context of a rapidly evolving pandemic, multiple organizations have released guidelines stating that all organs from potential deceased donors with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection should be deferred, including from otherwise medically eligible donors found to have mild or asymptomatic SARS‐CoV‐2 discovered on routine donor screening. In this article, we critically examine the available data on the risk of transmission of SARS‐CoV‐2 through organ transplantation. The isolation of SARS‐CoV‐2 from nonlung clinical specimens, the detection of SARS‐CoV‐2 in autopsy specimens, previous experience with the related coronaviruses SARS‐CoV and MERS‐CoV, and the vast experience with other common RNA respiratory viruses are all addressed. Taken together, these data provide little evidence to suggest the presence of intact transmissible SARS‐CoV in organs that can potentially be transplanted, specifically liver and heart. Other considerations including ethical, financial, societal, and logistical concerns are also addressed. We conclude that, for selected patients with high waitlist mortality, transplant programs should consider accepting heart or liver transplants from deceased donors with SARS‐CoV‐2 infection.

Use of Extracorporeal Membrane Oxygenation (ECMO) in Acute Myocarditis - Insights from a National Inpatient Database

Purpose Acute myocarditis can be a challenging entity to manage, and may require the use of extracorporeal membrane oxygenation (ECMO), if it is severe enough. However, there is a lack of large, nationally representative studies examining the use of ECMO in patients with acute myocarditis. In this study we used a large national inpatient database to investigate the use of ECMO in acute myocarditis. Methods We queried the 2013-14 National Inpatient Sample for all adult patients (aged 18+ years) admitted with a diagnosis of acute myocarditis using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 422.0, 422.9x and 429.0, and patients requiring ECMO use (ICD-9-CM code 39.65). We then used complex samples multivariable regression to identify predictors of ECMO use. All results are weighted, and adjusted odds ratios (aOR) are presented with 95% confidence intervals (CI). SPSS version 25 (SPSS, IBM) was used for all statistical analyses. Results We identified 16,590 patients (weighted) with an admission diagnosis of acute myocarditis. Of these, 200 (1.2%) required ECMO. Patients in the ECMO group were younger (mean age 40.1 +- 15.5 years vs non-ECMO 46.8 +- 18.3 years; P Conclusion In our analysis of a national inpatient database, we found that ECMO was utilized in a small percentage of hospitalizations for acute myocarditis, and was associated with significantly increased mortality. However, mortality associated with ECMO use in our study may be related to more severe presentation of acute myocarditis. Further work is needed to identify predictors of improved survival in patients with acute myocarditis who require ECMO.

Should we fear infarct-like myocarditis?

IntroductionInfarct-like myocarditis is the common presentation of acute myocarditis with a good prognosis, mentioned in the literature. The restriction of physical activity for up to 6 months is usually recommended. The aim of our study was to show the characteristic features and specificity of this particular presentation of myocarditis and to evaluate its prognosis, relative to physical activity, after hospital discharge. MethodsFrom 2012 to 2016, 93 patients were hospitalized with acute myocarditis at the University Hospital of Pilsen, 73 (78%) of them had infarct-like myocarditis and were evaluated by basic diagnostic parameters.Thirty-two patients with infarct-like myocarditis were involved in our prospective observational study where echocardiography (ECHO), magnetic resonance imaging (MRI) including late gadolinium enhancement (LGE) volume, bicycle ergometry (BE) as well as troponin screening tests were regularly performed. None of the patients were professional athletes.One month after hospital discharge, all patients underwent bicycle ergometry without any load limitation. After the 1-month follow-up, patients were allowed to increase physical exertion gradually to included job performance. ResultsInitially, mild left ventricular systolic dysfunction was found in 43.8%, that was normalized before the first outpatient follow-up. Other patients had normal systolic function. Initially, all of the patients had significantly elevated troponin level. After 1 and 6 months, hypersensitive troponin values were under the 99th percentile of the healthy population. All of the patients had positive LGE in subepicardial localization. After 1 month, the LGE volume median had decreased by up to 53% and after 6 months it had decreased by up to 40% of the original value. The achieved exertion during BE, at the 6-month follow-up (9.7±2.2 METs) was statistically significantly better than after the 1-month follow-up (8.9±2.1 METs, p=0.0023). On the last BE follow-ups (9.3±2.1 METs), no significant change was seen (p=0.2331). The average follow-up time was 2 years. ConclusionInfarct-like myocarditis was the most common presentation of acute myocarditis during the observation time. No patient had an early recurrence of the disease (i.e., within 1 year) and no left ventricular (LV) systolic dysfunction was developed. Infarct-like myocarditis has a specific feature that differs from other types of myocarditis. It has good prognosis, which is independent of physical exertion starting 1 month after hospital discharge.

Acute Myocarditis with Infarct-like Presentation in a Pediatric Population: Role of Cardiovascular Magnetic Resonance

Chest pain is a typical symptom of acute myocarditis in adolescents. It may be indistinguishable from myocardial ischemia so it is called "infarct-like pattern." Cardiovascular magnetic resonance has an important role as a non-invasive diagnostic tool. The aim of our study is to provide a description of an acute myocarditis series with infarct-like pattern and to evaluate the cardiovascular magnetic resonance role in a pediatric population. We included all pediatric patients (0-16years) admitted to our hospital (May 2007-May 2016) with clinical diagnosis of acute myocarditis and infarct-like presentation (chest pain, EKG alterations, and released cardiac biomarkers). Diagnosis was confirmed with cardiovascular magnetic resonance using Lake Louise criteria. Seven patients (five males, two females) with a median age of 14years (12.5-15.2) were included. All patients showed ST-segment changes and released cardiac biomarkers. Three patients had left ventricular hypertrophy and two presented mild systolic left ventricular dysfunction. All patients had at least two positive Lake Louise criteria. Late gadolinium enhancement was positive in all of them. With a median follow-up of 23months (8-47), all of them are alive, with no cardiac symptoms and normal ventricular function. Infarct-like pattern is a typical presentation of acute myocarditis in adolescents. CMR should be performed in this population and may be considered as a first-line diagnostic tool. Its high sensitivity in infarct-like acute myocarditis may allow us to avoid endomyocardial biopsy. Unlike what was described in adults, late gadolinium enhancement does not imply worse outcome in our series.

Late Detection of Left Ventricular Dysfunction Using Two-Dimensional and Three-Dimensional Speckle-Tracking Echocardiography in Patients with History of Nonsevere Acute Myocarditis

Acute myocarditis (AM) often involves the left ventricular (LV) subepicardium that might be displayed by cardiac magnetic resonance even late after the acute phase. In the absence of global or regional LV dysfunction, conventional transthoracic echocardiography (TTE) does not accurately identify tissue sequelae of AM. We sought to evaluate the diagnostic value of two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography to identify patients with a history of AM with preserved LV ejection fraction (LVEF). Fifty patients (group 1: age, 31.4±10.5years; 76% males) with a history of cardiac magnetic resonance-confirmed diagnosis of AM (according to the Lake Louise criteria) were retrospectively identified and then (21.7±23.4months later) evaluated by complete echocardiography including 2D and 3D speckle-tracking analysis, as well as 50 age- and gender-matched healthy controls (group 2: age, 31.2±9.5years: 76% males). Patients with a history of severe clinical presentation of AM (sudden death, ventricular arrhythmia, heart failure, alteration of LVEF) were excluded. At diagnosis, peak troponin and C-reactive protein were 11.97 (interquartile range, 4.52-25.92) μg/L and 32.3 (interquartile range, 14.85-70.45) mg/L, respectively. Mean delay between acute phase and follow-up study TTE was 21.7±23.4months. LVEF was not statistically different between groups (62.1% vs 63.5%, P=.099). Two-dimensional global longitudinal strain (GLS) was lower in magnitude in group 1 (-17.8% vs -22.1%, P<.0001) as were 2D layer-specific subepicardial GLS (-15.4% vs -19.7%, P<.0001) and subendocardial GLS (-20.71% vs -25.08%, P<.0001). Three-dimensional global longitudinal, circumferential, area, and radial strains were lower in magnitude in group 1 (-11.80% vs -14.98%, P<.0001; -12.57% vs -15.12%, P<.0001; -22.28% vs -25.87%, P<.0001; 31.47% vs 38.06%, P<.0001, respectively). Receiver operating characteristic curve analysis showed that subepicardial GLS displayed a better diagnostic performance to detect sequelae of AM as compared with GLS (area under the curve=0.97 vs 0.93, P=.045). In patients with a history of AM, a subtle LV dysfunction can be detected by 2D and 3D speckle-tracking echocardiography, even though LVEF is conserved, adding incremental information over conventional TTE.

Acute coronary syndrome or myocarditis? The role of multimodality imaging

The presentation of acute myocarditis varies. In some cases it mimics acute coronary syndrome. In this case we demonstrated the potential role of multi-modality cardiac imaging to quickly exclude coronary artery disease and confirm the diagnosis of myocarditis.

Transient left ventricular wall thickening in a 14-year-old girl with influenza A myocarditis

We describe a case of influenza A myocarditis and transient left ventricular wall thickening in a 14-year-old girl presenting with acute heart failure. Admission echocardiogram revealed significant left ventricular hypertrophy with depressed left ventricular systolic function. The aetiology of the ventricular thickening was demonstrated to be myocardial oedema using cardiac magnetic resonance imaging. The natural course of this unusual clinical presentation of acute myocarditis and the importance of cardiac magnetic resonance imaging in this challenging clinical setting are discussed.