Myocarditis Research Articles

Introduction: Thyroid dysfunction is frequently observed in patients with acute myocarditis and has been described across multiple studies. Although both conditions may share common pathogenic mechanisms, the prognostic implications of their coexistence remain unclear. Hypothesis: We hypothesize that thyroid dysfunction, is associated with a more severe clinical course and adverse in-hospital outcomes in patients with acute myocarditis. Methods: We conducted a retrospective cohort study of 119 patients diagnosed with acute myocarditis by cardiac magnetic resonance imaging (CMR) at a tertiary care center in Bogotá, Colombia, from January 2022 to December 2024. Sociodemographic data, clinical presentation, laboratory findings, treatment, and in-hospital outcomes were extracted from medical records. Patients were categorized into three groups: euthyroid, hyperthyroid, and hypothyroid. Statistical comparisons were performed using chi-square and ANOVA tests. A p-value <0.05 was considered statistically significant. Results: The mean age was 42.3 years, and 30.2% were female. Thyroid dysfunction was present in 36 patients (30.2%): 17 (14.2%) with hyperthyroidism and 19 (15.9%) with hypothyroidism. There were no significant differences between groups in terms of age, sex, prodromal symptoms, or biventricular function by CMR. However, patients with hypothyroidism had a trend toward longer hospital stays and demonstrated a significantly higher incidence of ventricular arrhythmias during hospitalization (OR: 8.8, 95% CI: 1.80–43.6), despite arrhythmias being an overall infrequent complication. In-hospital mortality was rare across all groups. Conclusions: Thyroid dysfunction, particularly hypothyroidism, is common among patients with acute myocarditis and may be associated with a higher risk of ventricular arrhythmias. These findings highlight the potential prognostic relevance of thyroid function assessment in myocarditis and suggest that concurrent management of thyroid dysfunction could influence clinical outcomes.

Introduction/Background: Genetic cardiomyopathy (GEN-CM) has overlapping features of inflammation and arrhythmias with cardiac sarcoidosis (CS) and non-genetic myocarditis (MYOC); however, the treatments are very different, making it critical to distinguish them accurately. Radiomics is an AI-based approach to pixel-based analysis for CMR images with the potential for broad implementation for this diagnostic problem using publicly available software. Research Questions/Hypothesis: We tested the hypothesis that CMR radiomics would have an area under the curve (AUC) of ≧ 0.8 for diagnosing GEN-CM relative to CS and MYOC. Methods/Approach: The study design was a secondary analysis of an observational cohort from an academic medical center. We evaluated contrast-enhanced CMR images from 145 patients in the University of Minnesota CMR Registry with either GEN-CM, CS, or MYOC. Radiomics was applied to SSFP cine end-diastolic images and late gadolinium enhancement (LGE) images. Principal component analysis (PCA) generated combinations of radiomics features ordered based on the percent of variance explained, and the most predictive PCA predictors for the two models (Model 1: GEN-CM v. CS; Model 2: GEN-CM v. MYOC) were chosen. Bootstrapping (resampling with replacement) was used to generate 100 different samples from the original dataset, and receiver operating characteristic (ROC) curves with 95% confidence bands were used to report the AUC and 95% CI for each model. Results/Data: Among 145 patients (age 43.2 ± 16.0 years, 31% female) who had GEN-CM (n=50), CS (n=47) or MYOC (n=48), the most prominent features influencing the diagnosis were the maximum mean absolute deviation in pixel intensity, the maximum run length non-uniformity (normalized), and the large area emphasis feature, which were all higher in GEN-CM v. CS and GEN-CM v. MYOC ( Figure 1 ). Four PCA predictors (three LGE predictors and one cine predictor) were identified for Model 1, and four PCA predictors (two LGE predictors and 2 cine predictors) were identified for Model 2. The AUC for Model 1 was 0.90 (95% CI 0.83 to 0.95), and the AUC for Model 2 was 0.88 (AUC 0.81 to 0.94), indicating a high level of performance ( Figure 2 ). Conclusions: Radiomics applied to CMR cine and LGE images provides a high level of performance for the diagnosis of genetic cardiomyopathy, accurately distinguishing it from cardiac sarcoidosis and non-genetic myocarditis with contributions from both CMR imaging sequences.

Systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are auto-immunological disorders with recognized cardiovascular involvement, such as myocarditis. Although myocarditis is an uncommon event, its impact can be considerable. The present study compares the cardiovascular outcomes following acute myocarditis in SLE, SSc, and SLE-SSc overlap patients with those with no autoimmune disorder. Three retrospective, propensity-matched cohort studies using the TriNetX Research Network compared adults with acute myocarditis and comorbid SLE (n=322), SSc (n=96), or SLE-SSc overlap (n=343) with matched non-autoimmune myocarditis controls. Matching variables included sex, race, insurance, and Charlson Comorbidity Index. Outcomes measured included 1-year all-cause mortality, myocardial infarction (MI), acute heart failure, stroke, acute kidney injury (AKI), arrhythmia, readmission, and 3-point major adverse cardiovascular events (MACE: heart failure, stroke, or cardiac arrest). Odds ratios (OR) and 95% CIs were determined. No differences were noted in 1-year mortality, heart failure, stroke, AKI, or arrhythmia between the autoimmune cohorts and controls. However, SLE patients had a higher risk for MI (10.1% vs 4.5%, OR 0.42 [0.19–0.91], p=0.024), and SLE-SSc overlapping patients had a higher 3-point MACE (12.6% vs 5.3%, OR 0.39 [0.19–0.81], p=0.009). Readmission was more frequent in both SLE and overlapping cohorts and did not achieve statistical significance. No such differences were noted in the SSc cohort. Whereas most cardiovascular complications in patients with autoimmune versus non-autoimmune myocarditis were similar, SLE and SLE-SSc overlapped patients had an increased risk for adverse outcomes. The propensity for increased MI in SLE can be ascribed to underlying vasculopathic autoimmunity superimposed by myocarditis. Patients with SLE-SSc overlap would be a group with increased systemic immune dysregulation, as indicated by their increased MACE. Although with lower numbers, the SSc patients did not have an increased risk, perhaps because of pathophysiologic dissimilarities or limitations of the sample size. The observations underscore the importance of intensified cardiovascular monitoring in patients with autoimmune myocarditis, particularly in patients with SLE or overlapping syndromes. Prospective studies are indicated to confirm the above observations and for the development of management strategies.

Introduction: Immune checkpoint inhibitors (ICI) can trigger cardiac-related immune adverse effects by activating T cells against myocardial self-antigens, which can cause myocarditis, arrhythmias, and cardiomyopathy. SGLT2 inhibitors have anti-inflammatory properties and can help regulate immune cells, which might play a role in preventing immune related cardiac adverse events in patients on ICI. Study Aim: To evaluate SGLT2 inhibitor impact on preventing major adverse cardiovascular events in patients receiving ICI Methods: This retrospective cohort study utilized the TrinetX Global Collaborative Network to analyze patients aged ≥ 18 from January 2014 and May 2025. Two cohorts were identified: cohort 1 included patients receiving ICI in combination with SGLT2 inhibitors, and cohort 2 received ICIs without SGLT2 inhibitors. Both cohorts excluded individuals with cardiomyopathy or heart failure (HF). The outcomes assessed were HF, atrial fibrillation/flutter (AF), acute myocardial infarction (AMI), myocarditis, and mortality. Absolute risk, relative risk (RR), 95% confidence interval (CI), and p-value were calculated using TrinetX platform. Kaplan-Meier analysis was used to estimate survival probabilities and log-rank tests to compare the survival curves. Results: After propensity score matching, both cohorts had 2,862 patients with mean age at index diagnosis 68 with 35% females and 62% males. SGLT-2 group had 0% incidence of heart failure vs 1.103% in control group with a p-value of < 0.0001, and RR being 0 as there were no events in cohort 1. There was lower risk of AF in SGLT-2 group compared to non-user group (RR 0.7, 95% CI: 0.535-0.916, p-value 0.009). The risk of AMI (RR 0.85, 95% CI: 0.592-1.212, p-value 0.3625) and myocarditis (RR 1.001, 95% CI: 0.417-2.401, p-value 0.998) was similar between both groups. All-cause mortality was lower in SGLT-2 inhibitor group compared to control group (RR 0.658, 95% CI: 0.613-0.706, p-value < 0.0001) Conclusion: SGLT2 inhibitors were associated with a lower incidence of HF, AF, and all-cause mortality in patients receiving ICIs, with no significant impact on AMI or myocarditis. Further studies are needed to explore the potential benefits of SGLT2 inhibitors for primary prevention of major adverse cardiovascular events in this patient population.

Introduction: Immune checkpoint inhibitor (ICI) induced hypothyroidism is a common immune related adverse event during cancer immunotherapy, but the association with cardiovascular (CV) risk is unknown. Methods: All patients receiving ICI therapy for solid organ malignancy from 2015-2023 at a single academic center were identified (n~6000), and an algorithm designed to detect ICI-associated thyroid dysfunction (ICI-TD) was developed using thyroid stimulating hormone labs and thyroid hormone replacement medications. Sensitivity and specificity were assessed using clinician diagnosis as the gold standard. Cancer types and CV events were identified using ICD codes. Chi-Squared was used where appropriate, and univariate logistic regression was used to assess the likelihood of each CV outcome, with results visualized on a forest plot. Kaplan-Meier curves were generated to illustrate the time to onset of cardiac events in ICI-TD and Non-ICI-TD populations. Results: The algorithm (Figure 1A) was found to have a sensitivity of 92% and a specificity of 93% to detection of ICI-TD. Among patients receiving ICI therapy with normal thyroid function prior to their first dose of ICI therapy (Baseline Population; n=4720), ICI-TD was observed in 795 (16.8%) patients with significant variation across cancer types (p<0.001). Compared against those without ICI-TD (n=3925), coronary artery disease (CAD) (9.75% vs 5.36%, p<0.001) and arrhythmias (8.78% vs 6.51%, p=0.03) were associated with ICI-TD (Figure 1B). Heart failure, acute coronary syndrome, myocarditis, and pericarditis were not associated with ICI-TD. There were no significant differences in the time to onset of arrhythmias (p=0.22) or CAD (p=0.21) between patients with ICI-TD and those without (Figures 1C and 1D). Conclusion(s): An algorithm can detect ICI-TD with high sensitivity and specificity. ICI-TD is associated with long term risk of CAD and arrhythmia, highlighting a high-risk group that may benefit from increased CV monitoring and risk modification.

Introduction: Chronic inflammatory cardiomyopathy (infl-CMP) is a persistent cardiac disorder that often arises from the progression of acute myocarditis. This condition is marked by chronic heart failure, arrhythmias, and reduced quality of life. Hydroxychloroquine (HCQ), known for its immunomodulatory properties, has been suggested as a potential treatment option for reducing chronic inflammation in these individuals. Research Questions: Can HCQ combined with prednisolone (PDN) improve cardiovascular outcomes in patients with chronic infl-CMP compared to PDN alone? What are the effects of this combination on heart function and inflammatory markers? Furthermore, is HCQ safe for long-term use in this setting? Methods: We conducted a multicenter, randomized controlled trial involving 50 patients diagnosed with chronic infl-CMP post-fuminant myocarditis (FM). Participants were randomly assigned to receive either a combination of HCQ and PDN or PDN alone over 12 months. The primary outcome measured was a composite of cardiovascular events, including time to cardiovascular death or heart transplant, hospitalization for heart failure, recurrence of myocarditis, and the requirement for a permanent pacemaker or implantable cardioverter-defibrillator (ICD). Secondary outcomes included changes in LVEF, LVIDd, hs-cTnI, NT-proBNP, hs-CRP, and ESR from baseline to 12 months. Results: The trial demonstrated that HCQ combined with PDN significantly improved primary cardiovascular outcomes compared to PDN monotherapy, with a hazard ratio (HR) of 0.28 (95% confidence interval [CI] 0.11–0.71). There were notable improvements in LVEF and reductions in LVIDd, hs-cTnI, NT-proBNP, and hs-CRP levels in the combination treatment group. Specifically, the estimated between-group differences in changes were as follows: LVEF improved by 8.01 (95% CI: 5.27 to 10.76), LVIDd decreased by -4.02 (95% CI: -6.20 to -1.85), hs-cTnI reduced by -98.40 (95% CI: -174.80 to -5.90), NT-proBNP by -399.30 (95% CI: -877.00 to -14.00), hs-CRP by -1.65 (95% CI: -3.10 to -0.40), and ESR by -1.70 (95% CI: -4.58 to 1.19). Importantly, no serious drug-related adverse events were reported, and HCQ treatment normalized the levels of 16 plasma cytokines. Conclusion: The combination of HCQ and PDN significantly enhances cardiovascular outcomes, heart function, and inflammatory inhibition in patients with chronic infl-CMP without serious adverse events.

Description of case: A 79-year-old man with hypertension, diabetes, and mild asthma presented after three days of weakness, abdominal discomfort, and dyspnea without chest pain. Initial evaluation showed a troponin of 45,044 ng/L (normal < 14) and ST-elevations in V1–V5 with reciprocal depressions in II and III, prompting STEMI protocol activation. Emergent catheterization revealed nonobstructive coronary disease and an elevated left ventricular end-diastolic pressure of 28 mmHg. Echocardiography demonstrated severe left ventricular systolic dysfunction (EF 30 percent), mid-septal akinesis, and severe mitral regurgitation. Labs revealed relative eosinophilia with a normal absolute count, lymphopenia, and negative ANCA. Cardiac MRI showed heterogeneous mid-wall late gadolinium enhancement in the basal to mid-septum with elevated T1 and extracellular volume, suggesting nonischemic cardiomyopathy. After MRI, he developed fulminant cardiogenic shock with tachycardia, respiratory failure, and altered mental status requiring intubation, mechanical ventilation, norepinephrine, and vasopressin. Continuous venovenous hemofiltration was started for acute kidney injury. Endomyocardial biopsy confirmed eosinophilic myocarditis with extensive eosinophilic infiltration. Infectious workup—including blood cultures, respiratory viral panel, and serologies for Trichinella and Strongyloides—was negative. High-dose IV methylprednisolone (1 g daily) led to rapid improvement: extubation on day 5, vasopressor weaning, and transition to oral prednisone. Discussion: This case illustrates the diagnostic challenge of ANCA-negative eosinophilic myocarditis presenting as STEMI. Massive troponin elevation and classic ST elevations suggested myocardial infarction with nonobstructive coronary arteries (MINOCA). Rapid deterioration and definitive biopsy revealed eosinophilic myocarditis. The absence of peripheral eosinophilia and negative ANCA delayed diagnosis, highlighting the necessity of endomyocardial biopsy in unexplained acute myocarditis with shock. Early recognition and prompt high-dose steroids are critical, as patients can deteriorate quickly but recover dramatically with treatment. Clinicians should suspect eosinophilic myocarditis in elderly patients with STEMI-like presentations and negative angiography, even if ANCA and absolute eosinophil counts are normal.

Background: Differentiating between immune checkpoint inhibitor (ICI) myocarditis and non-ICI myocarditis is clinically important. Cardiovascular magnetic resonance (CMR) is a well-established method for diagnosing acute myocarditis. The value of CMR for distinguishing ICI myocarditis from non-ICI myocarditis remains unclear, which this study sought to determine. Methods: A total of 54 patients (n = 26 ICI myocarditis; n = 28 non-ICI myocarditis) underwent clinical CMR for the assessment of cardiac function (cines), myocardial fibrosis (native T1-mapping, extracellular volume [ECV] fraction, late gadolinium enhancement [LGE]) and myocardial oedema (native T2-mapping). Results: ICI myocarditis patients were older than non-ICI myocarditis patients (75 years [71–78] vs. 39 years [30–64]; p < 0.001). Both groups had similar left ventricular (LV) ejection fraction (58 ± 11% vs. 58 ± 6%; p = 0.970). ICI myocarditis and non-ICI myocarditis patients also had similar native myocardial T1 values (1041 ± 84 ms vs. 1063 ± 60 ms; p = 0.281), native myocardial T2 values (59 ± 6 ms vs. 59 ± 6 ms; p = 0.943) and ECV (0.32 ± 0.07 vs. 0.31 ± 0.04; p = 0.403). Native myocardial T1 values (Rho = −0.553) and ECV (Rho = −0.502) were significantly associated with LVEF in non-ICI myocarditis patients (both p < 0.05). There was no significant association between myocardial T1 values, T2 values or ECV, with LVEF, in ICI myocarditis patients (all p < 0.05). Non-ICI myocarditis patients had a greater frequency of LGE in the LV compared to ICI myocarditis patients (89% vs. 52% p = 0.005). However, the pattern of LGE was similar between the two patient groups (mostly subepicardial and/or mid-wall). Conclusions: In this single centre retrospective cohort, the findings suggest that quantitative parametric mapping methods by CMR may not differentiate between ICI vs. non-ICI myocarditis. Further work is needed to assess the value of CMR for diagnosing standalone ICI myocarditis.

Ventricular arrhythmia in patients with acute myocarditis: A cohort study.

Hwangryunhaedok-tang (HLHDT) is a traditional Korean and Chinese medicinal formula known for its anti-inflammatory properties. This study evaluated the breadth of HLHDT’s therapeutic potential by analyzing literature on its anti-inflammatory effects. A database search (PubMed and CNKI) retrieved 2,013 relevant articles, of which 48 papers were selected for systematic review. Clinical studies showed its effectiveness in treating various inflammatory conditions, including radiation dermatitis, atopic dermatitis, ulcerative colitis, diabetic foot infections, periodontitis, oral diseases, and acute viral myocarditis. The analysis revealed that HLHDT effectively modulated inflammation across models including suppression of inflammatory pathways in lipopolysaccharide-treated A549 cells, and showing autophagy-related effects in RAW 264.7 cells. In addition, research on conditions such as atopic dermatitis, atherosclerosis, and acute lung injury determined its efficacy in treating a range of inflammatory diseases. The capacity of HLHDT to significantly reduce many proinflammatory markers underscored its extensive anti-inflammatory effects, and highlighted its potential in addressing both acute and chronic inflammatory conditions. However, the predominance of studies conducted in China and variability in methodological quality may limit the generalizability of the findings. Therefore, there is a need for further clinical research to validate the effects of HLHDT, and explore its underlying mechanisms of action. This study demonstrated the potential of HLHDT as a significant therapeutic agent in traditional Chinese medicine.

Background/objectives Myocarditis can progress to a fulminant form, leading to severe heart failure and mortality. Inflammation and nutritional status play critical roles in disease progression. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score is a novel, easily accessible biomarker that reflects both systemic inflammation and nutritional status. This study aimed to evaluate the prognostic value of the HALP score in predicting fulminant myocarditis among patients diagnosed with acute myocarditis. Methods A total of 124 patients diagnosed with acute myocarditis were retrospectively enrolled in this single-center study. Patients were categorized into non-fulminant and fulminant myocarditis groups based on diagnostic criteria. Results The median age of the patients was 24 years, 14.5% was female. Twenty-three of these patients (18.5%) exhibited fulminant myocarditis. Troponin I, C-reactive protein (CRP), white blood cell (WBC), and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly higher in the fulminant myocarditis group, while the HALP score was lower ( p < 0.001 for all). Multivariable regression analysis identified WBC, NT-proBNP and HALP score as independent predictors of fulminant myocarditis ( p = 0.029, p = 0.011 and p = 0.046, respectively). The optimal cut-off value of the HALP score was 4.12 for predicting fulminant myocarditis, with an area under the curve of 0.814. Beyond its diagnostic utility, a low HALP score was also significantly associated with worse clinical outcomes. Conclusion The HALP score can independently predict the development of fulminant myocarditis in acute myocarditis patients.

Aims: Acute myocarditis is a clinical condition that poses a challenge in clinical management, with its heterogeneous character ranging from clinically silent, mildly self-limiting conditions to serious, life threatening conditions including cardiogenic shock and fatal outcomes. Sacubitril/valsartan affects both the renin-angiotensin-aldosterone system (blockage by valsartan) and the natriuretic peptide system (neprilysin inhibition by sacubitril) pathways. It is one of the main therapies in the management of heart failure with reduced ejection fraction. We evaluated patients who received sacubitril/valsartan therapy with subacute clinically suspected myocarditis and mild reduced ejection fraction. Methods: We evaluated 7 patients who diagnosed subacute clinically suspected myocarditis with mild reduced ejection fraction. On admission, all patients took sacubitril/valsartan. We analyzed those patients in terms of the echocardiographic findings at presentation and following time (at 6 months). Results: The study group included 5 male (71%) and 2 female (29%). During admission, all patients took sacubitril/valsartan. NYHA function and BNP levels at present (class-3, 704.75±143) decrease after 6-monthfollow-up. (class-2, 65.17±14.58). Left ventricle diastolic diameter, left atrium diameter, and E/ E’ at present (56.04±3.07, 41.77±1.23 and 14.83±0.25) decrease after 6-month follow-up. (48.04±2.07, 37.57±1.23 and 7.7±0.14). Ejection fraction increased after 6-month follow-up (from 42.13±2.63) to 51.13±2.63). Conclusion: In subacute clinically suspected myocarditis, sacubitril/valsartan therapy could be an effective alternative.

The aim of this study was to evaluate and update the effects of immunosuppressive therapy on heart failure outcomes in patients aged16years or older with biopsy-proven inflammatory myocardial disease. We performed a systematic review and an aggregate data meta-analysis of studies evaluating the effects of such therapy in acute and chronic myocarditis or inflammatory dilated cardiomyopathy. Studies were chosen based on criteria related to clinical relevance for therapeutic decisions and measured outcomes in left ventricular ejection fraction (LVEF) and New York Heart Association classification (NYHA) at 3, 6, and 12months. Data sources included PubMed, Embase, Ovid, and ClinicalTrials.gov, with manual reference checks. Data extraction and risk-of-bias assessments were performed by two independent reviewers. We used a random-effects model and assessed heterogeneity with I2 and τ2 statistics. . Seven eligible studies with a total of 594 patients were included, that investigated clinical course of acute and chronic myocarditis and inflammatory dilated cardiomyopathy. At 3months, the pooled standardized mean difference (SMD) for LVEF was 0.97 (95% CI -0.05 to 1.99; p > 0.05). At 6months, the pooled SMD was 0.48 (95% CI -1.31 to 2.28), and at 12months, -0.01 (95% CI -1.65 to 1.62). For NYHA classification, pooled SMDs were 0.02 (95% CI -0.21 to 0.25) at 3months and -0.22 (95% CI -1.56 to 1.11) at 12months. In all cases, confidence intervals crossed zero. Heterogeneity remained high (I2 = 92-97%), reflecting substantial variability across studies. In patients with acute or chronic myocarditis or inflammatory dilated cardiomyopathy, immunosuppressive therapy does not improve key echocardiographic or clinical parameters when adding new data from randomized controlled trials (RCTs). High heterogeneity suggests variability in patient populations and protocols, highlighting the need for well-designed RCTs. There is still no evidence to support routine endomyocardial biopsy in non-severe disease, as it will not impact symptomatic treatment, even if inflammation is present.

123I-MIBG has been shown to visualize impaired cardiac neuronal function, but data of this imaging modality in patients with acute myocarditis are scarce. Nonetheless, an association with reduced cardiac function has been observed previously. The aim of this study was to establish and evaluate semi-quantitative and quantitative parameters in 123I-MIBG scintigraphy and SPECT/CT in patients with acute myocarditis and identify associations with left ventricular ejection fraction (LVEF) and biomarkers. Eight patients with acute myocarditis and a gender and age-matched control group who underwent 123I-MIBG scintigraphy and SPECT/CT were retrospectively analysed. Semi-quantitative Heart-to-Mediastinum (H/M) ratio and washout rate were calculated, additionally SPECT/CT system calibration and a whole-heart-segmentation were used for absolute quantification of tracer uptake. ROC analysis for the prediction of acute myocarditis and correlation of imaging parameters with LVEF and serological biomarkers was performed. Seven patients (87.5%) showed visually decreased tracer uptake. Planar imaging parameters showed significant differences compared to the control group (e.g. H/M ratio 1.6 ± 0.3 vs. 2.3 ± 0.8, p < 0.05), as well as multiple quantitative parameters e.g. SUVmean (1.7 ± 0.5 vs. 3.0 ± 1.0; p < 0.01). Additionally, correlation between imaging parameters and LVEF (e.g. SUVmax r = 0.85, p < 0.01) and NT-proBNP (e.g. H/M r = - 0.88, p < 0.05) was observed. 123I-MIBG visualizes impairment of cardiac neuronal function in patients with acute myocarditis and is associated with reduced ejection fraction and elevated NT-proBNP. We could establish an absolute quantification approach that could offer novel diagnostic opportunities for disease assessment and risk stratification, which will be focused on further studies.

Neutrophil-to-lymphocyte ratio for risk stratification in acute myocarditis across the left ventricular ejection fraction spectrum.

IntroductionVentricular assist devices (VADs) are used in children usually as a bridge to transplantation and occasionally also as a bridge to recovery, e.g., for acute myocarditis. However, in cases of recovery, weaning criteria are not well defined and protocols are scarce.Case reportWe report our first experience with weaning of biventricular assist device (EXCOR® Pediatric, Berlin Heart GmbH, Germany) in a 3-year-old boy due to recovery.DiscussionThe weaning and explantation processes were based on clinical experience, local hospital practices, and collaboration with the Berlin Heart team.ConclusionRegular echocardiographic assessments, weaning attempts, and downsizing of the EXCOR pumps may facilitate device weaning.

Large-scale studies assessing the risk of chronic active myocarditis (CAM) and chronic heart failure (CHF) following acute myocarditis are limited. This multicenter (seven hospitals) retrospective cohort study included patients diagnosed with acute myocarditis from April 2013 to January 2024. We employed logistic regression and Cox regression to develop models predicting the risk of CAM as primary outcome and CHF as second outcome, respectively. This study included 483 patients with acute myocarditis proven by cardiac magnetic resonance imaging or endomyocardial biopsy. The predictive model for CAM incorporated continuous renal replacement therapy, extracorporeal membrane oxygenation, lactate dehydrogenase, cardiac troponin I (cTnI), left atrial diameter, and duration of hospitalization, achieving an area under the curve (AUC) of 0.881 (95% CI, 0.829-0.934) with clinical applicability confirmed by decision curve analysis (DCA). The model for predicting CHF included cardiopulmonary resuscitation or defibrillation, C-reactive protein, lactate dehydrogenase, alanine aminotransferase, creatine kinase MB isoenzyme, cTnI, and left ventricular end-diastolic diameter, yielding an AUC of 0.872 (95% CI, 0.788-0.925) with clinical utility supported by DCA. Internal and external validation results were consistent with development cohort. Restricted cubic spline analysis revealed that the risks of CAM and CHF significantly increased only when cTnI exceeded 10000 pg/mL. Notably, CAM significantly increased the risk of subsequent CHF development with a hazard ratio 9.43 (95% CI, 5.55-16.02; P < 0.001). This study developed two predictive models that exhibited strong performance in discrimination, accuracy, and clinical applicability. A cTnI level of 10,000 pg/mL can serve as a threshold for predicting CAM and CHF. Furthermore, patients with CAM had a significantly higher risk of progressing to CHF in later stages.

Since March 2024, the European Center for Disease Prevention and Control has reported increased Parvovirus B19 (B19V) infections across 14 European countries. While often self-limiting in healthy children, B19V may cause severe disease in vulnerable populations. This multicenter prospective study aimed to characterize the clinical presentation of B19V infection in hospitalized children and identify risk factors for severe outcomes. Data were collected through the INF-ACT pediatric surveillance system, as part of the National Recovery and Resilience Plan. Children hospitalized with confirmed B19V infection were enrolled from January to December 2024 in 10 Italian INF-ACT centers. A total of 135 children were included (median age 7.6 years, interquartile range 4.4-9.9), with 78.5% of cases occurring between April and July 2024. Acute myocarditis (20.7%) and neurological complications (17.8%) were the most frequent severe manifestations. Myocarditis was significantly associated with younger age (P < 0.001), longer hospital stays (median 19.5 vs. 6.5 days; P = 0.0018) and higher intensive care unit (ICU) admission rates (71.4% vs. 20.8%; P < 0.001). Multivariate analysis showed myocardial involvement increased the risk of ICU admission over 20-fold (P < 0.001). Although often mild, B19V infection can cause severe complications in children, particularly myocarditis and neurological involvement. Prompt recognition is essential, even in the absence of classic features like erythema infectiosum, to ensure timely monitoring and management of potentially life-threatening outcomes.

ObjectiveVarious clinical indicators can increase the likelihood of early identification of fulminant myocarditis, the identification of which is important for early treatment.MethodThe medical records of all patients (n = 269) who were diagnosed with acute myocarditis between January 2014 and December 2023 were retrospectively analyzed. Patients were divided into two groups: the nonfulminant myocarditis group (n = 229) and the fulminant myocarditis group (n = 40). Baseline demographics, laboratory findings, electrocardiograms, echocardiograms, and treatment regimens were compared between the two groups via multifactorial analysis. A receiver operating characteristic (ROC) curve was used to explore the predictive value of related factors.ResultsThe median age of patients with fulminant myocarditis was significantly greater than that in the nonfulminant group (P = 0.015). The presenting symptoms at admission varied and included fever and respiratory, digestive, and circulatory symptoms. Among them, fever and hypotension were more common in the fulminant myocarditis group (P < 0.05), and vomiting was significantly more common in the nonfulminant myocarditis group (P = 0.017). Logistic regression analysis revealed that N-terminal pro-B-type natriuretic peptide (NT-proBNP), lactate (Lac), alanine aminotransferase (ALT), cardiac troponin I (cTnI), chest distress, and hypotension were early risk factors for fulminant myocarditis. ROC curve analysis demonstrated that NT-proBNP, ALT, cTnI, and Lac can serve as predictors for the early diagnosis of fulminant myocarditis. The optimal predictive values for these markers are 2,783.5 pg/ml for NT-pro BNP, 34.5 U/L for ALT, 0.2 µg/ml for cTnI, and 3.05 mmol/L for Lac.ConclusionsThis study revealed that NT-proBNP, cTnI, ALT, and Lac can serve as predictive factors for the early identification of fulminant myocarditis. These findings emphasize the importance of early identification and timely diagnosis for improving the overall prognosis of patients.

BackgroundPrimary Sjögren's syndrome (pSS) is a chronic autoimmune inflammatory disorder primarily affecting the exocrine glands. A subset of patients exhibits extraglandular manifestations, including cardiovascular involvement. Among them, myocarditis is a rare complication, and its pathogenesis remains poorly understood.Case presentationAn 85-year-old man with a persistent dry mouth was admitted to our hospital with high-grade fever, nausea, fatigue, and urinary disturbance. On day 2, the patient developed multiple cerebral infarctions and bilateral acute otitis media. Fever and inflammatory response without leukocytosis and cardiac imaging findings indicative of active myocarditis, and normal cardiac function suggested acute viral myocarditis, for which supportive treatments were initiated. On day 6, the patient experienced acute heart failure with severely reduced ejection fraction and cardiogenic shock. An endomyocardial biopsy was performed following transient peripheral eosinophilia in serial blood samples, which revealed acute eosinophilic myocarditis (AEM). A thorough diagnostic evaluation for eosinophilia revealed pSS, leading to the final diagnosis of pSS-associated AEM. Systemic high-dose corticosteroid treatment improved the general condition of the patient, except for a left ventricular apical aneurysm. Nevertheless, the patient's post-treatment hospital course was complicated by serious digestive involvement, leading to death from septic shock.ConclusionsTo our knowledge, this is the first case of severe pSS complicated by AEM. This case highlights the importance of early therapeutic intervention for AEM and early comprehensive surveillance of systemic organs for pSS. Furthermore, this case provides new insights into the pathogenesis of pSS-associated myocarditis.