Myocarditis Presenting Research Articles

P301 FULMINANT COVID–19 RELATED MYOCARDITIS: A CASE REPORT

The caseA 58–year–old man presented to ED because of fever, non–productive cough and worsening dyspnea. The patient’s medical history was unremarkable. On examination there was a hypoxic respiratory failure and the clinical picture rapidly evolved towards a cardiogenic shock characterized by altered mental status and cool extremities. Vital parameters: peripheral blood pressure was of 60/30 mmHg, pulse rate of 126 bpm, respiratory rate of 30 breaths/min, temperature of 38 °C. Two episodes of ventricular fibrillation were resolved by electrical shocks. The nasopharyngeal swab tested positive for COVID–19 on real–time reverse transcriptase–polymerase chain reaction assay. Arterial blood gas analysis showed a severe metabolic acidosis with hyperlactacidaemia (pH 7.26, excess basis–22 mEq/L, lactates 10 mmol/dL) and hypoxaemia. Situation evolved towards an end–organ hypoperfusion associated with multisystem organ failure (MOF). High resolution chest CT demonstrated bilateral ground glass opacities consisting of COVID–19 related interstitial pneumonia. 12–leads ECG demonstrated sinus rhythm with diffuse concave ST–segment elevation. T–T echocardiogram showed: 1) severely thickened LV walls; 2) decreased LV systolic function; 3) segmental wall motion abnormalities consisting of akinesis of the LV distal segments with relatively preserved function at the base; 4) LVEF) of 25%; 5) pericardial effusion. Thickened LV walls meant myocardial inflammatory infiltration/edema and the final diagnosis was FULMINANT COVID–19 related MYOCARDITIS. Patient underwent oro–tracheal intubation+invasive ventilation. An intra–aortic balloon pump (IABP) was placed on top of adrenaline (0.07μg/kg/min), and noradrenaline (0.1μg/kg/min) was added for worsening hypotension (systolic blood pressure: 80/67/60 mmHg). Additional therapy consisted of intravenous high dose diuretics, methyprednisolone, tucilizumab, immunoglobulin, ceftriaxone, remdesivir. After 3 weeks, patient recovered a good respiratory and haemodinamic status, LV wall thicknesses decreased and EF increased to normal values. The final outcome was favorable. DiscussionThe prevalence of fulminant myocarditis among COVID–19 patients is unclear. This simultaneous presentation of fulminant myocarditis and COVID–19 pneumonia favors an alternative pathogenetic pathway with possible acute replication and direct dissemination of the virus through the blood or the lymphatic system from the respiratory tract to the myocardium.

COVID-19 Myocarditis: Prognostic Role of Bedside Speckle-Tracking Echocardiography and Association with Total Scar Burden.

SARS-CoV2 infection, responsible for the COVID-19 disease, can determine cardiac as well as respiratory injury. In COVID patients, viral myocarditis can represent an important cause of myocardial damage. Clinical presentation of myocarditis is heterogeneous. Furthermore, the full diagnostic algorithm can be hindered by logistical difficulties related to the transportation of COVID-19 patients in a critical condition to the radiology department. Our aim was to study longitudinal systolic cardiac function in patients with COVID-19-related myocarditis with echocardiography and to compare these findings with cardiac magnetic resonance (CMR) results. Patients with confirmed acute myocarditis and age- and gender-matched healthy controls were enrolled. Both patients with COVID-19-related myocarditis and healthy controls underwent standard transthoracic echocardiography and speckle-tracking analysis at the moment of admission and after 6 months of follow-up. The data of 55 patients with myocarditis (mean age 46.4 ± 15.3, 70% males) and 55 healthy subjects were analyzed. The myocarditis group showed a significantly reduced global longitudinal strain (GLS) and sub-epicardial strain, compared to the control (p < 0.001). We found a positive correlation (r = 0.65, p < 0.0001) between total scar burden (TSB) on CMR and LV GLS. After 6 months of follow-up, GLS showed marked improvements in myocarditis patients on optimal medical therapy (p < 0.01). Furthermore, we showed a strong association between baseline GLS, left ventricular ejection fraction (LVEF) and TSB with LVEF at 6 months of follow-up. After a multivariable linear regression analysis, baseline GLS, LVEF and TSB were independent predictors of a functional outcome at follow-up (p < 0.0001). Cardiac function and myocardial longitudinal deformation, assessed by echocardiography, are associated with TSB at CMR and have a predictive value of functional recovery in the follow-up.

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).

Pediatric Myocarditis: What Have We Learnt So Far?

Myocarditis is an inflammatory disease of the myocardium that is troublesome to diagnose and manage, especially in children. Since the introduction of endomyocardial biopsy (EMB), new diagnostic tools have provided useful data. Especially when enhanced with immunohistochemistry and polymerase chain reaction (PCR) studies, EMB remains the gold standard for the diagnosis. Notably, cardiac magnetic resonance (MRI) is a non-invasive tool that can confirm the diagnosis and has a particular usefulness during the follow-up. The causes of myocarditis are heterogeneous (mostly viral in children). The course and outcome of the illness in the pediatric population represent a complex interaction between etiologic agents and the immune system, which is still not fully understood. The clinical presentation and course of myocarditis vary widely from paucisymptomatic illness to acute heart failure refractory to therapy, arrhythmias, angina-like presentation and sudden cardiac death. In this setting, cardiac biomarkers (i.e., troponins and BNP), although unspecific, can be used to support the diagnosis. Finally, the efficacy of therapeutic strategies is controversial and not confirmed by clinical trials. In this review, we summarized the milestones in diagnosis and provided an overview of the therapeutic options for myocarditis in children.

Overlapping Etiologies in a Young Patient with Severe Myocarditis: A Case Report

Introduction Etiological identification of young patients with heart failure should always be a medical goal. In this scenario, infectious myocarditis is a possible diagnosis and, when it occurs, it has a benign course in the majority of cases. However, congenital heart diseases or familial forms of cardiomyopathy should be considered in differential diagnosis and/or concomitantly, particularly in more severe presentations of myocarditis. In these cases, in addition to specific investigation for myocarditis, which may include clinical evaluation, imaging exams, laboratory [...]

54-Year-Old Man With Acute Dyspnea on Exertion

54-Year-Old Man With Acute Dyspnea on Exertion

Ten questions about eosinophilic myocarditis

Eosinophilic myocarditis is a rare form of myocardial inflammation characterized by interstitial infiltration by eosinophils. Clinical presentation may vary from complete absence of symptoms to fulminant myocarditis with cardiogenic shock, to chronic heart failure due to progression to restrictive cardiomyopathy. The main causes of eosinophilic myocarditis are hypersensitivity reactions secondary to drug exposure, eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome and infections. Antibiotics and agents acting on the central nervous system are the most frequently reported drugs capable of causing hypersensitivity myocarditis. Infections are usually due to intestinal parasites. Imaging techniques together with clinical and laboratory data help rising the suspicion of eosinophilic myocarditis. However, the definite diagnosis is made by endomyocardial biopsy. The evidence of eosinophilic infiltrate among myocytes allows to start an immunosuppressive treatment, usually based on corticosteroids, that are the cardinal therapy for eosinophilic myocarditis. Anticoagulation should be undertaken in case of endoventricular thrombosis, which frequently complicates eosinophilic myocarditis, mainly those cases associated with hypereosinophilic syndrome and eosinophilic granulomatosis with polyangiitis. In this focused review, we will try to provide answers to the most common questions on the causes, presentation, diagnosis, treatment, and outcomes of eosinophilic myocarditis.

Atypical arrhythmogenic presentation of giant cell myocarditis diagnosed after heart transplant

A 50-year-old woman reporting chest discomfort and found to have ventricular tachycardia (VT) on electrocardiogram (ECG) with a reduced ejection fraction on echocardiogram was transferred to our hospital (figure). The patient had no significant medical history.

Achy Breaky Heart: A Case of Lymphocytic Myocarditis Mimicking Takotsubo Cardiomyopathy

<h3>Introduction</h3> Myocarditis is an inflammatory disease of the myocardium that may be due to immune system activation, infection or exposure to toxic substances. The clinical presentation and trajectories encompass a wide spectrum. We present a case of cardiogenic shock fulfilling both the Mayo criteria for myocarditis and the WHO criteria for Takotsubo cardiomyopathy, distinguished by endomyocardial biopsy. <h3>Case Report</h3> A 65-year-old female with a history of mitral valve repair, hypertension and diabetes presented with acute onset chest pain and dyspnea. She denied recent viral illness. Upon examination, she was tachycardic with elevated JVP, crackles bilaterally, and bilateral lower extremity edema. EKG showed sinus tachycardia with PVCs and anteroseptal/lateral ischemic changes. Labs revealed troponin peaking in the 90s and leukocytosis. She underwent left and right cardiac catheterization revealing essentially clean coronaries, severely reduced LVEF 10-20%, severe hypokinesis of the inferoapical segments consistent with Takotsubo cardiomyopathy and hemodynamics consistent with cardiogenic shock. Cardiac MRI demonstrated findings consistent with myocarditis. The patient was successfully managed by a multidisciplinary team. Due to differential diagnoses of Takotsubo cardiomyopathy and myocarditis, serologies for cardiotropic viruses, urine toxicology, and autoimmune workup were performed and were negative. Therefore, an endomyocardial biopsy was obtained revealing lymphocytic and histiocytic infiltrates with localized areas of fiber necrosis. The lymphoid infiltrates were predominantly T-cells, highlighted with CD45 and CD3 stains, consistent with findings of lymphocytic myocarditis. <h3>Summary</h3> This case highlights lymphocytic myocarditis presenting similarly to Takotsubo cardiomyopathy in an older female. This is particularly thought-provoking given that myocarditis must be excluded in all cases of Takotsubo cardiomyopathy per the Mayo criteria. It illustrates the importance of recognizing the clinical presentation of myocarditis and distinguishing it from other secondary cardiomyopathies to properly manage these patients.

A Real Circuit Breaker: Hyperhemolysis Syndrome Related to the VA-ECMO Circuit?

<h3>Introduction</h3> Myocarditis is an inflammatory disease of cardiac muscle caused by a variety of infectious and non-infectious conditions. Viral infection is the most frequent cause of myocarditis; however, herpes simplex virus 1 (HSV-1) infection causing myocarditis has been rarely described. We present a case of a young woman with HSV-1 viremia and fulminant myocarditis presenting with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO), complicated by hyperhemolysis. <h3>Case Report</h3> A 35 year-old immunocompetent woman with moderate alcohol consumption presented to hospital with a 4-day history of fever and flu-like symptoms. She was fully vaccinated for COVID-19 two months prior to symptom onset. Her COVID-19 testing was negative and she was discharged home. She returned to hospital 4 days later in cardiogenic shock. Transthoracic echocardiogram demonstrated LVEF of 30% with a small pericardial effusion. Coronary angiogram revealed normal coronaries. She was placed on peripheral VA-ECMO for worsening cardiogenic shock. Due to inadequate LV unloading, she underwent atrial septostomy. Five days after VA-ECMO cannulation, HSV-1 was detected in the blood and she was started on intravenous acyclovir. Her ECMO course was complicated by acute kidney injury requiring dialysis, and hyperhemolysis with a peak LDH of 12,000 U/L. The mechanism of hemolysis was attributed to an intravascular process (plasma free hemoglobin 7487 mg/L, normal < 150 mg/L) likely from a combination cold agglutinins and the mechanical circuit. Interestingly the membrane pressure gradient was within normal. The patient received treatment with plasmapheresis (Table 1), and was eventually decannulated after 12 days following hemodynamic improvement. <h3>Summary</h3> This case report highlights a rare viral cause of fulminant myocarditis and emphasizes the need for collaboration among various specialists in the management of complex cases.

The Diagnostic Role of Echocardiographic Strain Analysis in Patients Presenting with Chest Pain and Elevated Troponin: A Multicenter Study

Myocarditis presenting as acute chest pain with elevated troponins without significant cardiac compromise is rare in previously healthy children, often referred to as myopericarditis. Diagnosis is challenging, as conventional echocardiographic measures of systolic function can be normal. The aim of this study was to demonstrate the diagnostic utility of strain imaging in this scenario. This was a multicenter, retrospective study including patients presenting with chest pain and elevated troponin from 10 institutions who underwent cardiac magnetic resonance imaging and transthoracic echocardiography within 30days of each other (group 1). Findings were compared with those among 19 control subjects (group 2). Clinical data and conventional echocardiographic and cardiac magnetic resonance imaging data were collected. Echocardiography-derived strain was measured at the core laboratory. Group 1 was divided into subgroups as myocarditis positive (group 1a) or negative (group 1b) on cardiac magnetic resonance imaging on the basis of established criteria. Group 1 included 108 subjects (88 in group 1a, 20 in group 1b). Although all groups had normal mean fractional shortening and mean left ventricular ejection fraction, group 1 had significantly lower ejection fraction (56.8±7.0%) compared with group 2 (62.3±4.9%; P<.005) and fractional shortening (31.2±4.9%) compared with group 2 (34.1±3.5%; P<.05). Additionally, peak global longitudinal strain (GLS) was markedly abnormal in group 1 (-13.9±3.4%) compared with group 2 (-19.8±2.1%; P<.001). In subgroup analysis, GLS was markedly abnormal in group 1a (-13.2±3.0%) compared with group 1b (-17.3±2.6%; P<.001). Fifty-four subjects underwent follow-up echocardiography (46 in group 1a, eight in group 1b), with mean a follow-up time of 10±11months. At follow-up, whereas ejection fraction and fractional shortening returned to normal in all patients, abnormalities in strain persisted in group 1, with 22% still having abnormal GLS. Moreover, mean GLS was more abnormal in group 1a (-16.1±2.6%) compared with group 1b (-17.4±1.2%; P<.05). The present study demonstrates that echocardiographic GLS is significantly worse in subjects with myopericarditis presenting with chest pain and elevated troponins compared with control subjects even when conventional measures of systolic function are largely normal and that these abnormalities persisted over time.

A Review of the Role of Imaging Modalities in the Evaluation of Viral Myocarditis with a Special Focus on COVID-19-Related Myocarditis.

Viral myocarditis is inflammation of the myocardium secondary to viral infection. The clinical presentation of viral myocarditis is very heterogeneous and can range from nonspecific symptoms of malaise and fatigue in subclinical disease to a more florid presentation, such as acute cardiogenic shock and sudden cardiac death in severe cases. The accurate and prompt diagnosis of viral myocarditis is very challenging. Endomyocardial biopsy is considered to be the gold standard test to confirm viral myocarditis; however, it is an invasive procedure, and the sensitivity is low when myocardial involvement is focal. Cardiac imaging hence plays an essential role in the noninvasive evaluation of viral myocarditis. The current coronavirus disease 2019 (COVID-19) pandemic has generated considerable interest in the use of imaging in the early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related myocarditis. This article reviews the role of various cardiac imaging modalities used in the diagnosis and assessment of viral myocarditis, including COVID-19-related myocarditis.

Return to Play after SARS-CoV-2 Infection in Competitive Athletes of Distinct Sport Disciplines in Italy: A FMSI (Italian Federation of Sports Medicine) Study.

Background: SARS-CoV-2 can lead to several systemic complications, including myocardial injuries; these might be worsened by heavy physical activity. The optimal approach to cardiac risk stratification following SARS-CoV-2 infection in athletes for a safe return to play (RTP) still needs defining. The aim of this study was to assess the prevalence of abnormal RTP test results, according to the protocol of Italian Federation of Sport Medicine (FMSI), which was endorsed by the Italian Ministry of Health, potentially representing COVID-19-associated cardiac injuries. Methods: This was a prospective, multicenter, observational study. All consecutive competitive athletes who underwent COVID-19 RTP testing protocol from 1 May to 31 July 2021, across 60 Italian Centers of Sports Medicine, were enrolled in the study. Athletes were tested at least 30 days after negativization of the nasopharyngeal swab (or immediately after negativization in professional athletes or Probable Olympians). A 12-lead electrocardiography at rest and during maximal incremental exercise test with continuous O2 saturation monitoring and an echocardiographic examination were part of the protocol. In athletes with “moderate” disease (NHI classification), 24 h ECG monitoring (to be performed on a training day) and Magnetic Resonance Imaging (MRI) were also performed. Results: A total of 4143 athletes (67.8% males and 32.2% females) (53% > 18 years, 20% 18–35 years and 16% > 35 years), from more than 40 different sport disciplines, were included in the study. The mean age was 22.5 ± 13.3 years, with ages ranging from 8 to 80 years. Of these athletes, 52.3% were asymptomatic, 46.4% manifested mild symptoms, 1.1% and 0.14% had moderate or severe symptoms, respectively, while critical illness was evident in one athlete. Abnormal echocardiographic findings were detected in 80 cases (1.9%), and pericarditis in 7 cases (0.2%); all were from mildly symptomatic athletes. Arrhythmic events were recorded in 239 athletes, with 224 (5.4%) in the exercise test and 15 (0.4%) during 24 h ECG monitoring. Ventricular arrhythmias were observed in 101 (2.4%) athletes from the total population (mostly isolated or couples of premature ventricular beats): 91 in the exercise test and 10 during 24 h ECG monitoring. Cardiac magnetic resonance was performed in 34 athletes; the presence of myocarditis was confirmed in 5 athletes (0.12% of the total population, 14.7% of athletes in which MRI was performed). Conclusions: According to our results, cardiac complications from SARS-CoV-2 in asymptomatic or mildly symptomatic competitive athletes are rare, and an RTP assessment based on symptoms and ECG-monitored exercise test would ensure a safe RTP in these athletes.

Systematic analysis of drug-associated myocarditis reported in the World Health Organization pharmacovigilance database

While multiple pharmacological drugs have been associated with myocarditis, temporal trends and overall mortality have not been reported. Here we report the spectrum and main features of 5108 reports of drug-induced myocarditis, in a worldwide pharmacovigilance analysis, comprising more than 21 million individual-case-safety reports from 1967 to 2020. Significant association between myocarditis and a suspected drug is assessed using disproportionality analyses, which use Bayesian information component estimates. Overall, we identify 62 drugs associated with myocarditis, 41 of which are categorized into 5 main pharmacological classes: antipsychotics (n = 3108 reports), salicylates (n = 340), antineoplastic-cytotoxics (n = 190), antineoplastic-immunotherapies (n = 538), and vaccines (n = 790). Thirty-eight (61.3%) drugs were not previously reported associated with myocarditis. Antipsychotic was the first (1979) and most reported class (n = 3018). In 2019, the two most reported classes were antipsychotics (54.7%) and immunotherapies (29.5%). Time-to-onset between treatment start and myocarditis is 15 [interquartile range: 10; 23] days. Subsequent mortality is 10.3% and differs between drug classes with immunotherapies the highest, 32.5% and salicylates the lowest, 2.6%. These elements highlight the diversity of presentations of myocarditis depending on drug class, and show the emerging role of antineoplastic drugs in the field of drug-induced myocarditis.

Unpacking the mysteries of Parvovirus B19 Myocarditis

Myocarditis is an inflammatory disease of the heart muscle, most often caused by viral infections. Its diagnosis can be difficult due to the heterogeneity of presentations that often mimic other common cardiological conditions, such as acute coronary syndrome (ACS) and heart failure. Although most cases are benign and self-limiting, it can also take on a more malignant course complicated by life-threatening arrhythmias, cardiogenic shock, and sudden cardiac death (SCD). A certain proportion of patients progress to develop dilated cardiomyopathies (DCMO). The developed world has experienced a shift in viral pathogens detected in patients with acute myocarditis over the past 20 years, and Parvovirus B19 (PVB19) and human herpesvirus-6 (HHV6) are currently the most commonly identified viruses in the myocardium of patients with viral myocarditis. The clinical relevance and pathological roles of these viruses however remain questioned. This focused review aims to use 2 cases of PVB19 myocarditis managed by our unit to explore issues related to the clinical presentation, diagnosis, treatment and prognosis of PVB19 myocarditis along with controversies surrounding the pathogenic role and clinical relevance of PVB19 in myocarditis.

Should We Stay or Should We Go? A Review of Current Management of Non-COVID-19 Acute Myocarditis in a Rural Setting and a Suggested Risk-Based Approach

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed “risk-based approach” [[1]Ammirati E. Frigerio M. Adler E.D. Basso C. Birnie D.H. Brambatti M. et al.Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document.Circ Heart Fail. 2020; 13 (e007405)Crossref PubMed Scopus (103) Google Scholar], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care. We conducted a retrospective review of all presentations coded as myocarditis to a rural Australian centre, between May 2019 and June 2021. Twenty-four (24) patients were identified. Five of these were transferred for tertiary level care, all of whom had myocarditis confirmed on cardiac magnetic resonance imaging (CMRI). The estimated AM incidence was 43 per million. Factors associated with transfer were younger age (26 vs 49yrs, p=0.03) and higher troponin I rise (30,986 vs 6,124 ng/L, p=0.01). Reasons for transfer included cardiogenic shock, tachyarrhythmias, concern for potential deterioration, and diagnostic uncertainty. There was one mortality, unrelated to myocarditis. Applying the Ammirati risk-based criteria to transferred patients suggested 1 patient was high risk, 1 was medium risk and 3 were low risk but required CMRI for diagnostic clarity. A risk-based model, based on clinical findings, echocardiography, and cardiac monitoring, safely selects patients requiring tertiary care. However, without routine use of CMRI, there may be the tendency to transfer some patients subsequently found to be low risk, thereby over-utilising resources. Planned wider availability of CMRI in rural settings might be expected to ameliorate this difficulty.

Clinical characteristics and prognostic factors of myocarditis associated with the mRNA COVID-19 vaccine.

To analyze the clinical presentation and outcomes of myocarditis after administration of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) messenger RNA (mRNA) vaccine. Nine case series and 15 case reports (74 patients) of myocarditis after administration of the BNT162b2 or mRNA‐1273 vaccine were reviewed from PubMed, Scopus, Embase, and Web of Science. We analyzed clinical manifestations, diagnostic findings, and outcomes. In addition, we performed a pooled analysis and investigated risk factors leading to admission to the intensive care unit and recovery with conservative care. Most patients were male (94.6%), and the median age (range) was 17.6 (14–70) years. Patients who received the BNT162b2 (n = 58, 78.4%) vaccine presented fewer systemic symptoms and left ventricular dysfunction than mRNA‐1273 recipients. Although patients under 20 years experienced more fever and myalgia, they had better ejection fraction and less prominent myocardial inflammation in magnetic resonance imaging than older patients. The clinical course of all patients was favorable without mortality, and one‐third of patients resolved with conservative care alone. Risk factor analyses revealed that patients with gastrointestinal symptoms required intensive care (odds ratio: 20.3, 95% confidence interval 1.90–217, p = 0.013). The risk of fatality in myocarditis subjected to mRNA vaccination seems to be low. However, patients with gastrointestinal symptoms received more intensive care, and a significant proportion of patients recovered with conservative management.

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

Distinct Microbial Communities in Dilated Cardiomyopathy Explanted Hearts Are Associated With Different Myocardial Rejection Outcomes.

BackgroundIdiopathic dilated cardiomyopathy (IDCM) myocardial inflammation may be associated with external triggering factors such as infectious agents. Here, we searched if moderate/severe heart transplantation rejection is related to the presence of myocardial inflammation in IDCM explanted hearts, associated with microbial communities.MethodReceptor myocardial samples from 18 explanted hearts were separated into groups according to post-transplant outcome: persistent moderate rejection (PMR; n = 6), moderate rejection (MR; n = 7) that regressed after pulse therapy, and no rejection (NR; n = 5)/light intensity rejection. Inflammation was quantified through immunohistochemistry (IHC), and infectious agents were evaluated by IHC, molecular biology, in situ hybridization technique, and transmission electron microscopy (TEM).ResultsNR presented lower numbers of macrophages, as well as B cells (p = 0.0001), and higher HLA class II expression (p ≤ 0.0001). PMR and MR showed higher levels of Mycoplasma pneumoniae (p = 0.003) and hepatitis B core (p = 0.0009) antigens. NR presented higher levels of parvovirus B19 (PVB19) and human herpes virus 6 (HHV6) and a positive correlation between Borrelia burgdorferi (Bb) and enterovirus genes. Molecular biology demonstrated the presence of M. pneumoniae, Bb, HHV6, and PVB19 genes in all studied groups. TEM revealed structures compatible with the cited microorganisms.ConclusionsThis initial study investigating on infectious agents and inflammation in the IDCM explanted hearts showed that the association between M. pneumoniae and hepatitis B core was associated with a worse outcome after HT, represented by MR and PMR, suggesting that different IDCM microbial communities may be contributing to post-transplant myocardial rejection.

Long-term Results of Drug and Interventional Treatment in Patients with Morphologically Verified Idiopathic Arrhythmias

Aim. To study the late results of medical and interventional treatment in patients with morphologically verified nature of idiopathic arrhythmias.Methods. The prospective study included 20 patients (mean age 43.1±11.3 years, 10 female) with atrial fibrillation (AF), supraventricular and ventricular extrasystole, supraventricular and ventricular tachycardia, conduction disturbance without structural heart changes. In addition to the standard examination, the level of anti-heart antibodies was initially determined; endomyocardial biopsy (EMB) of the right ventricle with PCR study for the viral genome; DNA diagnostics (n=4), coronary angioraphy (n=6), skin biopsy (n=1) were performed. The median follow-up was 134 [128; 138] months.Results. By EMB in the initial examination were diagnosed: active (n=8)/borderline (n=3) infectious immune myocarditis; parvovirus-positive endomyocarditis (n=1); undifferentiated vasculitis (n=2); myocardial vasculitis (n=1); Fabry disease (n=1); arrhythmogenic right ventricular dysplasia (n=1); unspecified cardiomyopathy (n=2). Anti-heart antibodies were the most important in myocarditis diagnosis and monitoring. All patients with myocarditis/vasculitis (n=15) received its basic therapy: acyclovir (n=10); immunoglobulin G 10-12.5 g (n=2); hydroxychloroquine 200 mg/day (n=15); glucocorticoids (n=14); azathioprine 150 mg/day (n=2). The late results were evaluated in all patients with myocarditis. Initially, in 62.5% of patients a resistance of AF to all antiarrhythmic drugs was noted. After treatment the average frequency of AF paroxysms decreased (from 8 [5; 8] to 3 [1,25; 7,75] points). By the end of the follow-up, six patients underwent radiofrequency ablation (RFA) for AF, the full effect was achieved once. All patients without RFA have AF partially or completely resistant to drugs. Two patients (without RFA) died from ischemic stroke/ pulmonary embolism.Conclusion. Using EMB the causes of idiopathic arrhythmias (mainly AF) were diagnosed: immune inflammatory diseases in 75% and genetic in 25% of patients. As a result of complex treatment, the general burden of arrhythmias has decreased. But the presence of myocarditis and primary cardiomyopathy, without reducing the cardiac contractility and dilatation, does not allow achieving a stable antiarrhythmic effect. Lethality for 11 years was 10%. The causes of death were thromboembolic complications.