Impact of mechanical circulatory support and immunomodulation therapy on outcome of patients with fulminant myocarditis: Chinese registry of fulminant myocarditis.
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ABSTRACT:
SUBMITTER: Zhou N
PROVIDER: S-EPMC8492670 | biostudies-literature | 2021 Oct
REPOSITORIES: biostudies-literature
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Impact of mechanical circulatory support and immunomodulation therapy on outcome of patients with fulminant myocarditis: Chinese registry of fulminant myocarditis.
Zhou Ning N Zhao Yuhua Y Jiang Jiangang J Shen Lan L Li Junming J Wan Jing J Ma Xueping X Zhang Jing J Ammirati Enrico E Wang Dao Wen DW
Signal transduction and targeted therapy 20211006 1
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Project description:A 48-year-old woman suffered from cardiogenic shock with fulminant myocarditis following the second dose of COVID-19 vaccine (mRNA-1273). Venoarterial extracorporeal membrane oxygenation and Impella support were essential in achieving hemodynamic stability. Endomyocardial biopsy revealed lymphocytic infiltration with predominant immunostaining for CD8- and CD68-positive cells. The left ventricular ejection fraction improved significantly after treatment with mechanical circulatory support. Myocarditis following COVID-19 mRNA vaccination may also occur in middle-aged women; it may be fulminant and require mechanical circulatory support. Although our results suggest the involvement of cytotoxic T lymphocytes and macrophages, further investigation is needed before these can be established as pathogenetic mechanisms.
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| S-EPMC11769667 | biostudies-literature
Project description:A 49-year-old man, who had not been vaccinated against COVID-19 visited the hospital for fever and cough, and a PCR test for COVID-19 was positive on the Day X. Initially, there was no decrease in oxygen saturation and the patient was under observation as a mild case without medication. Five days after the onset (Day X + 5), chest pain appeared. Electrocardiogram showed widespread ST-segment elevation, and blood tests showed high levels of troponin I. However, given that there was no stenotic lesion on coronary computed tomography, myocarditis was suspected, and he was transferred to our hospital on the Day X + 6. We started treatment with lemdesivir and dexamethasone. On the Day X + 7, the patient developed decreased left ventricular ejection fraction, hypotension, and hyperlactatemia. We decided that mechanical circulatory support was necessary and an Impella 5.0 was inserted under ventilator management. The patient was successfully weaned from the Impella 5.0 on the Day X + 17, was transferred to the general ward on the Day X + 24, continued rehabilitation, and was discharged home on the Day X + 39 with no heart failure symptoms. In this case, we performed daily bedside echocardiography and chose the Impella 5.0 instead of extra corporeal membrane oxygenation (ECMO) because there were no findings of severe pneumonia or right heart failure. The Impella 5.0 device was inserted via an axillary artery approach, given that it provides more assisted flow than the Impella CP inserted through the inguinal route. Furthermore, early rehabilitation was possible due to the lack of restriction of the lower body.
| S-EPMC9440337 | biostudies-literature
Project description:BackgroundFulminant eosinophilic myocarditis (EM) is a rare and often fatal condition that may present atypically and be complicated by ventricular arrhythmias. Treatment involves high-dose corticosteroids to suppress eosinophilia, as well as increasing use of mepolizumab, an anti-interleukin-5 antibody with evidence for long-term efficacy and safety.Case summaryA 38-year-old woman presented to the emergency department with neck pain and fatigue, and after extensive investigation was diagnosed with EM secondary to idiopathic hypereosinophilic syndrome. The patient was treated with methylprednisolone for eosinophil suppression and warfarin due to the presence of biventricular apical thrombi. Despite previously stable haemodynamics, the patient had a cardiac arrest due to ventricular fibrillation on Day 11 of hospitalization, requiring 30 min of cardiopulmonary resuscitation and commencement of veno-arterial extracorporeal membrane oxygenation support due to refractory ventricular arrhythmias. The patient was urgently listed for heart transplant but a suitable match was not identified, and she was weaned to pharmacologic support on Day 34. The patient survived with minimal sequelae and has returned to full-time work. She remains on mepolizumab as a steroid-sparing agent, therapeutic anti-coagulation, and heart failure therapy.DiscussionThis report describes an atypical presentation of fulminant EM requiring weeks of mechanical circulatory support due to refractory arrhythmia rather than heart failure. The case also highlighted the benefits of non-invasive cardiac magnetic resonance imaging in both diagnosis and prognostication of EM, as well as the need to maintain a high index of suspicion for this rare disease.
| S-EPMC11635362 | biostudies-literature
Project description:Myocarditis is challenging to diagnose because of its various clinical manifestations. Fulminant myocarditis (FM) is a severe type of myocarditis characterized by heart failure, malignant arrhythmia, cardiogenic shock, and cardiac arrest. Its early diagnosis and timely treatment are crucial for a positive long-term prognosis. Here we report a case of 42-year-old woman who presented with fever, chest pain, and cardiogenic shock. An initial examination showed increased myocardial enzyme levels and diffuse ST-segment elevation. Urgent coronary angiography excluded coronary artery stenosis. Echocardiography revealed decreased left ventricular systolic function. Cardiac magnetic resonance imaging revealed cardiomyocyte necrosis and interstitial inflammatory edema. The patient was diagnosed with FM and administered antiviral and anti-infective agents, glucocorticoid, immunoglobulin, and supported with temporary cardiac pacemaker and positive airway therapy, and treated with continuous renal replacement therapy. As her clinical condition deteriorated rapidly, we immediately started an intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation. She was discharged on day 15 and recovered normally during follow-up. The early initiation of mechanical circulatory support and immunosuppression are life-saving tools for the treatment of FM.
| S-EPMC10154628 | biostudies-literature
Project description:BackgroundCoronavirus disease 2019 (COVID-19) spreading from Wuhan, Hubei province in China, is an expanding global pandemic with significant morbidity and mortality. Even though respiratory failure is the cardinal form of severe COVID-19, concomitant cardiac involvement is common. Myocarditis is a challenging diagnosis due to heterogeneity of clinical presentation, ranging from mild symptoms to fatal arrhythmia and cardiogenic shock (CS). The aetiology is often viral and endomyocardial biopsy (EMB) is the gold standard for definite myocarditis. However, the diagnosis is often made on medical history, clinical presentation, magnetic resonance imaging, and blood tests.Case summaryWe present a 43-year-old man with mixed connective tissue disease treated with hydroxychloroquine who rapidly developed CS 4 days from symptom onset with fever and cough, showing positive polymerase chain reaction nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. While computed tomography of the thorax was normal, high-sensitivity troponin T was elevated and electrocardiogram showed diffuse ST elevation and low voltage as signs of myocardial oedema. Echocardiography showed severe depression of left ventricular function. The myocardium recovered completely after a week with mechanical circulatory support (MCS). EMB was performed but could neither identify the virus in the cardiomyocytes, nor signs of inflammation. Still the most probable aetiology of CS in this case is myocarditis as a sole symptom of COVID-19.DiscussionCOVID-19 patients in need of hospitalization present commonly with respiratory manifestations. We present the first case of fulminant myocarditis rapidly progressing to CS in a COVID-19 patient without respiratory failure, successfully treated with inotropes and MCS.
| S-EPMC7799209 | biostudies-literature
Project description:BackgroundFulminant myocarditis is a rare and severe disease whose definite and etiological diagnoses rely on pathological examination. Albeit, myocardial biopsy can be associated with significant morbidity and mortality, its therapeutic consequences are unclear. We conducted a study to determine the diagnostic yield, the safety and the therapeutic consequences of myocardial biopsy in patients with fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (MCS).MethodsMonocenter, retrospective, observational cohort study in a 26-bed French tertiary ICU between January 2002 and February 2019. Inclusion of all fulminant clinically suspected myocarditis patients undergoing in-ICU myocardial biopsy while being on MCS. The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results.ResultsForty-seven patients (median age 41 [30-47], female 53%) were included: 55% died before hospital discharge, 34% could be bridged-to-recovery and 15% bridged-to-transplant. Myocardial biopsy was endomyocardial or surgical in 36% and 64% cases respectively. Tamponade requiring emergency pericardiocentesis occurred in 29% patients after endomyocardial biopsy. After adding the biopsy results in the Bonaca classification algorithm the percentage of definite myocarditis raised from 13 to 55% (p < 0.0001). The rate of biopsy-related treatments modifications was 13%, leading to patients' recovery in only 4% patients.ConclusionsIn clinically suspected myocarditis unweanable from MCS, myocardial biopsy increased the rate of definite myocarditis but was associated with a low rate of treatment modification and a significant proportion of adverse events. We believe the benefit/risk ratio of myocardial biopsy should be more carefully weighted in these frail and selected patients than suggested by actual guidelines. Further prospective studies are now needed to determine its value in patients under MCS.
| S-EPMC10471530 | biostudies-literature
Project description:BackgroundMyocarditis is a common cause of pediatric heart failure which may require mechanical circulatory support (MCS). The purpose of this study is to describe MCS strategies used in a nationwide cohort of pediatric patients with myocarditis, identify trends over time, and compare outcomes between MCS strategies.MethodsThis study utilized the Kids' Inpatient Database (KID), a national sample of administrative discharge data. KID admissions from 2003-2016 were queried using ICD-9/10 codes to identify those with a diagnosis of myocarditis. MCS outcomes were compared using logistic regression.ResultsOf 5,661 admissions for myocarditis, MCS was used in 424 (7.5%), comprised of extracorporeal membrane oxygenation (ECMO) in 312 (73.6%), including 32 (10.2%) instances of extracorporeal cardiopulmonary resuscitation (ECPR), temporary ventricular assist devices (tVAD) in 28 (6.6%), durable VAD (dVAD) in 42 (9.9%) and combination MCS in 42 (9.9%). MCS use increased over time (p=0.031), but MCS strategies did not significantly change. Mortality was high in the MCS group (28.3%). There was no difference in odds of death in the VAD only or combination MCS group compared to the non-ECPR ECMO group (p=0.07 and p=0.65, respectively).ConclusionMCS is used in 1 in 13 pediatric myocarditis cases, and MCS use is increasing over time with ECMO remaining the most frequently used modality. Mortality remains high in patients that receive MCS but does not differ between those receiving VAD or combination MCS as compared to non-ECPR ECMO on unadjusted analysis. Further prospective analysis is required to evaluate the relative effectiveness of MCS modalities in this disease.
| S-EPMC11251716 | biostudies-literature
Project description:BACKGROUND:There is scarce evidence for mechanical circulatory support (MCS) in patients with influenza-related myocarditis complicated by refractory cardiogenic shock (rCS). We sought to investigate the impact of MCS using combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and micro-axial flow pumps (the ECMELLA concept) in influenza-related myocarditis complicated by rCS. METHODS:This is a prospective, observational analysis from the single centre HAnnover Cardiac Unloading REgistry (HACURE) from two recent epidemic influenza seasons. We analysed patients with verified influenza-associated myocarditis complicated by rCS who were admitted to our intensive care unit (ICU) on MCS. Subsequently, we performed a propensity score (PS) matched analysis to patients with acute myocardial infarction (AMI) complicated by rCS and non-ischaemic cardiomyopathy (DCM) related rCS. RESULTS:We describe a series of seven patients with rCS-complicated influenza-related myocarditis (mean age 56±10?years, 58% male, influenza A (n=2)/influenza B (n=5)). No patient had been vaccinated prior to the influenza season. MCS was provided using combined VA-ECMO and Impella micro-axial flow pump. In two patients with out-of-hospital cardiac arrest, VA-ECMO had been implanted for extracorporeal cardiopulmonary resuscitation. All patients died within 18?days of hospital admission. By PS-based comparison to patients with AMI- or DCM-related rCS and combined MCS, 30-day mortality was significantly higher in influenza-related rCS. CONCLUSION:Despite initial stabilisation with combined MCS in patients with rCS-complicated influenza-related myocarditis, the detrimental course of shock could not be stopped and all patients died. Influenza virus infection potentially critically affects other organs besides the heart, leading to irreversible end-organ damage that MCS cannot compensate for and, therefore, results in a devastating outcome.
| S-EPMC7469974 | biostudies-literature