Enrico Ammirati1, Manlio Cipriani2, Marzia Lilliu2, Paola Sormani2, Marisa Varrenti2, Claudia Raineri2, Duccio Petrella2, Andrea Garascia2, Patrizia Pedrotti2, Alberto Roghi2, Edgardo Bonacina2, Antonella Moreo2, Maurizio Bottiroli2, Maria P Gagliardone2, Michele Mondino2, Stefano Ghio2, Rossana Totaro2, Fabio M Turazza2, Claudio F Russo2, Fabrizio Oliva2, Paolo G Camici2, Maria Frigerio2. 1. From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.). enrico.ammirati@ospedaleniguarda.it camici.paolo@hsr.it. 2. From Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy (E.A., M.C., M.L., M.V., A.G., F.M.T., M.F.); Cardiovascular Magnetic Resonance Unit (P.S., P.P., A.R.), Cardiovascular Imaging Service (A.M.), Cardiothoracic Anesthesiology Unit (M.B., M.P.G., M.M.), Cardiac Surgery Unit (C.F.R.), and Coronary Care Unit (F.O.), De Gasperis Cardio Center, and Pathology Laboratories (D.P., E.B.), Niguarda Hospital, Milan, Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (C.R., S.G.); Cardiac Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Italy (R.T.); and Vita Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.).
Abstract
BACKGROUND: Previous reports have suggested that despite their dramatic presentation, patients with fulminant myocarditis (FM) might have better outcome than those with acute nonfulminant myocarditis (NFM). In this retrospective study, we report outcome and changes in left ventricular ejection fraction (LVEF) in a large cohort of patients with FM compared with patients with NFM. METHODS: The study population consists of 187 consecutive patients admitted between May 2001 and November 2016 with a diagnosis of acute myocarditis (onset of symptoms <1 month) of whom 55 required inotropes and/or mechanical circulatory support (FM) and the remaining 132 were hemodynamically stable (NFM). We also performed a subanalysis in 130 adult patients with acute viral myocarditis and viral prodrome within 2 weeks from the onset, which includes 34 with FM and 96 with NFM. Patients with giant-cell myocarditis, eosinophilic myocarditis, or cardiac sarcoidosis and those <15 years of age were excluded from the subanalysis. RESULTS: In the whole population (n=187), the rate of in-hospital death or heart transplantation was 25.5% versus 0% in FM versus NFM, respectively (P<0.0001). Long-term heart transplantation-free survival at 9 years was lower in FM than NFM (64.5% versus 100%, log-rank P<0.0001). Despite greater improvement in LVEF during hospitalization in FM versus NFM forms (median, 32% [interquartile range, 20%-40%] versus 3% [0%-10%], respectively; P<0.0001), the proportion of patients with LVEF <55% at last follow-up was higher in FM versus NFM (29% versus 9%; relative risk, 3.32; 95% confidence interval, 1.45-7.64, P=0.003). Similar results for survival and changes in LVEF in FM versus NFM were observed in the subgroup (n=130) with viral myocarditis. None of the patients with NFM and LVEF ≥55% at discharge had a significant decrease in LVEF at follow-up. CONCLUSIONS: Patients with FM have an increased mortality and need for heart transplantation compared with those with NFM. From a functional viewpoint, patients with FM have a more severely impaired LVEF at admission that, despite steep improvement during hospitalization, remains lower than that in patients with NFM at long-term follow-up. These findings also hold true when only the viral forms are considered and are different from previous studies showing better prognosis in FM.
BACKGROUND: Previous reports have suggested that despite their dramatic presentation, patients with fulminant myocarditis (FM) might have better outcome than those with acute nonfulminant myocarditis (NFM). In this retrospective study, we report outcome and changes in left ventricular ejection fraction (LVEF) in a large cohort of patients with FM compared with patients with NFM. METHODS: The study population consists of 187 consecutive patients admitted between May 2001 and November 2016 with a diagnosis of acute myocarditis (onset of symptoms <1 month) of whom 55 required inotropes and/or mechanical circulatory support (FM) and the remaining 132 were hemodynamically stable (NFM). We also performed a subanalysis in 130 adult patients with acute viral myocarditis and viral prodrome within 2 weeks from the onset, which includes 34 with FM and 96 with NFM. Patients with giant-cell myocarditis, eosinophilic myocarditis, or cardiac sarcoidosis and those <15 years of age were excluded from the subanalysis. RESULTS: In the whole population (n=187), the rate of in-hospital death or heart transplantation was 25.5% versus 0% in FM versus NFM, respectively (P<0.0001). Long-term heart transplantation-free survival at 9 years was lower in FM than NFM (64.5% versus 100%, log-rank P<0.0001). Despite greater improvement in LVEF during hospitalization in FM versus NFM forms (median, 32% [interquartile range, 20%-40%] versus 3% [0%-10%], respectively; P<0.0001), the proportion of patients with LVEF <55% at last follow-up was higher in FM versus NFM (29% versus 9%; relative risk, 3.32; 95% confidence interval, 1.45-7.64, P=0.003). Similar results for survival and changes in LVEF in FM versus NFM were observed in the subgroup (n=130) with viral myocarditis. None of the patients with NFM and LVEF ≥55% at discharge had a significant decrease in LVEF at follow-up. CONCLUSIONS:Patients with FM have an increased mortality and need for heart transplantation compared with those with NFM. From a functional viewpoint, patients with FM have a more severely impaired LVEF at admission that, despite steep improvement during hospitalization, remains lower than that in patients with NFM at long-term follow-up. These findings also hold true when only the viral forms are considered and are different from previous studies showing better prognosis in FM.
Authors: Lili Zhang; Maeve Jones-O'Connor; Magid Awadalla; Daniel A Zlotoff; Paaladinesh Thavendiranathan; John D Groarke; Alexandra-Chloe Villani; Alexander R Lyon; Tomas G Neilan Journal: Curr Treat Options Cardiovasc Med Date: 2019-06-08
Authors: Syed S Mahmood; Michael G Fradley; Justine V Cohen; Anju Nohria; Kerry L Reynolds; Lucie M Heinzerling; Ryan J Sullivan; Rongras Damrongwatanasuk; Carol L Chen; Dipti Gupta; Michael C Kirchberger; Magid Awadalla; Malek Z O Hassan; Javid J Moslehi; Sachin P Shah; Sarju Ganatra; Paaladinesh Thavendiranathan; Donald P Lawrence; John D Groarke; Tomas G Neilan Journal: J Am Coll Cardiol Date: 2018-03-19 Impact factor: 24.094