Fulminant myocarditis: COVID or not COVID? Reinfection or co-infection?

We describe a unique case of fulminant myocarditis in a patient with presumed SARS-CoV-2 reinfection. Patient had initial infection 4 months backand had COVID-19 antibody at the time of presentation. Endomyocardial biopsy showed lymphocytic myocarditis, that is usually seen in viral myocarditis. The molecular diagnostic testing of the endomyocardial biopsy for cardiotropic viruses was positive for Parvovirus and negative for SARS-CoV-2. Authors highly suspect co-infection of SARS-CoV-2 and Parvovirus, that possibly triggered the immune cascade resulting in fulminant myocarditis. Patient was hemodynamically unstable with ventricular tachycardia and was supported on VA ECMO and Impella CP. There was impressive recovery of left ventricular function within 48 hours, leading to decannulation of VA ECMO in 72 h. This unique case was written by the survivor herself.

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Abstract 13428: Cardiac Troponin T Level is Associated With Myocardial Recovery in Fulminant Myocarditis

Circulation ◽

10.1161/circ.142.suppl_3.13428 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Toru Kondo ◽

Naoki Shibata ◽

shingo kazama ◽

Yuki Kimura ◽

Hideo Oishi ◽

...

Keyword(s):

Cardiac Troponin ◽

Troponin T ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Cardiac Troponin T ◽

Myocardial Recovery ◽

Ventricular Ejection Fraction ◽

Va Ecmo

Background: Fulminant myocarditis (FM) is a fatal disease that causes rapid-onset severe heart failure requiring inotropes or mechanical circulatory support (MCS). Because insufficient myocardial recovery requires durable left ventricular assist device or heart transplantation, the course of myocardial recovery should be predicted. Hypothesis: Cardiac troponins, which elevates due to myocardial damage, may associate with myocardial recovery in FM. Purpose: We aimed to investigate the relationship between cardiac troponin T (TnT) levels and myocardial recovery course in patients with FM. Method: We performed a retrospective medical record review of 19 patients with FM requiring MCS from May 2012 to January 2020. The serial changes of one-week left ventricular ejection fraction (LVEF) after MCS implantation according to TnT levels were evaluated. Results: Median age was 50 years and 10 patients were male. As for initial MCS, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pumping (IABP) were used in 13 patients, IABP in 4 patients, VA-ECMO in one patient, and impella 2.5 in one patient. Median peak TnT level within one week after MCS implantation were 4.43 (2.47 - 34.6) ng/mL. The patients were divided into High-TnT group and Low-TnT group according to median peak TnT level. All patients in both groups were alive until 7 days after MCS implantation, and LVEF on day 7 was significantly lower in the High-TnT group (Fig). TnT level was highest on day 1 and gradually decreased in the High-TnT group (Fig). Six patients died during hospitalization in the High-TnT group, in contrast, only one patient died in the Low-TnT group (p=0.020). Peak TnT level in patients with LVEF ≥30% (n=8) on day 7 was significantly lower than in patients with LVEF <30% (2.40 vs 13.5 ng/mL, p=0.012), however, other laboratory parameters showed no significant differences. Conclusion: Higher TnT level showed impaired myocardial recovery in patients with FM.

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Short-term use of “ECMELLA” in the context of fulminant eosinophilic myocarditis with cardiogenic shock

BMC Cardiovascular Disorders ◽

10.1186/s12872-020-01808-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Mintje Bohné ◽

Da-Un Chung ◽

Eike Tigges ◽

Hendrick van der Schalk ◽

Daniela Waddell ◽

...

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Left Ventricular ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Histopathological Diagnosis ◽

Severe Cardiogenic Shock ◽

Hemodynamic Deterioration ◽

Eosinophilic Myocarditis ◽

Va Ecmo

Abstract Background Eosinophilic myocarditis (EM) is a rare form of myocarditis. Clinical presentation is various, includes cardiogenic shock and can often be fatal. Diagnosis is based on myocardial eosinophilic infiltration in endomyocardial biopsy. Mechanical circulatory support (MCS) is often required in patients suffering from severe cardiogenic shock. Among the available MCS options the “ECMELLA” concept, a combination of left ventricular venting by Impella® device and extracorporeal life support (ECLS) is possibly able to provide the necessary time frame for diagnostics and initiation of anti-inflammatory medication in patients with fulminant myocarditis. Case presentation We report a case of a 38‐year‐old woman who was presented to us in severe cardiogenic shock, quickly requiring hemodynamic support by an Impella CP® device. Further dramatic hemodynamic deterioration accompanied by multi-organ dysfunction required escalation of MCS via ECLS as veno‐arterial extracorporeal membrane oxygenation (VA-ECMO). After histopathological diagnosis of EM, our patient was put on immunosuppressive therapy with prednisolone. Recovery of both right and left ventricular function allowed explanation of VA-ECMO on day 4 and further hemodynamic improvement allowed removal of the Impella® device on day 9. The patient was discharged after 7 weeks with fully restored cardiac function and in a good neurological state. Conclusions In severe cardiac shock due to fulminant EM the ECMELLA concept as bridge-to-recovery seems to be a valid option to provide the required time for diagnostics and specific therapy.

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Novel Combination of Impella and Extra Corporeal Membrane Oxygenation as a Bridge to Full Recovery in Fulminant Myocarditis

Case Reports in Critical Care ◽

10.1155/2012/459296 ◽

2012 ◽

Vol 2012 ◽

pp. 1-3 ◽

Cited By ~ 3

Author(s):

Sachin Narain ◽

Gian Paparcuri ◽

Thomas M. Fuhrman ◽

Richard B. Silverman ◽

William T. Peruzzi

Keyword(s):

Heart Failure ◽

Multiorgan Failure ◽

Systolic Dysfunction ◽

Viral Myocarditis ◽

Severe Heart Failure ◽

Left Ventricular ◽

Full Recovery ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Membrane Oxygenation

A 31-year-old male was transferred to our hospital with severe heart failure due to viral myocarditis. He progressed to multiorgan failure requiring intubation and maximal doses of multiple vasopressors. Circulatory support was provided with an Impella device as a bridge to an extracorporeal membrane oxygenation (ECMO) system. On full mechanical cardiovascular support, the patient's hemodynamic status improved and ECMO and Impella were explanted after 48 hours. Three days later, he was extubated and continued on to a full recovery. There are no specific therapies for fulminant myocarditis but first-line treatment is supportive care. ECMO is commonly used in patients with severe heart failure. In severe systolic dysfunction, left ventricular decompression is required to reduce myocardial wall stress, decrease myocardial oxygen requirements, and enhance the chances of recovery. The Impella, an active support system, is less invasive than classical decompressive techniques and is associated with lower requirements for blood products with fewer thromboembolic complications. This is the only case reported of the contemporary use of Impella and ECMO as a bridge to full recovery in an adult with myocarditis. It also presents a novel use of the Impella device in decompressing the left ventricle of an adult patient on ECMO.

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Multisystem inflammatory syndrome (MIS-C) in Pakistani children: A description of the phenotypes and comparison with historical cohorts of children with Kawasaki disease and myocarditis

PLoS ONE ◽

10.1371/journal.pone.0253625 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0253625

Author(s):

Shazia S. Mohsin ◽

Qalab Abbas ◽

Devyani Chowdhary ◽

Farah Khalid ◽

Abdul Sattar Sheikh ◽

...

Keyword(s):

Kawasaki Disease ◽

Clinical Laboratory ◽

Tertiary Care ◽

Viral Myocarditis ◽

Intravenous Immunoglobulins ◽

Left Ventricular ◽

World Health ◽

Fulminant Myocarditis ◽

Severe Left Ventricular Dysfunction ◽

Inflammatory Syndrome

Objectives To determine clinical, laboratory features and outcomes of Multisystem Inflammatory Syndrome in children (MIS-C) and its comparison with historic Kawasaki Disease (KD) and Viral Myocarditis (VM) cohorts. Methods All children (1 month– 18 years) who fulfilled the World Health Organization criteria of MIS-C presenting to two tertiary care centers in Karachi from May 2020 till August 31st were included. KD and VM admitted to one of the study centers in the last five years prior to this pandemic, was compared to MIS-C. Results Thirty children with median age of 24 (interquartile range (IQR)1–192) months met the criteria for MIS-C. Three phenotypes were identified, 12 patients (40%) with KD, ten (33%) VM and eight (26%) had features of TSS. Echocardiography showed coronary involvement in 10 (33%), and moderate to severe Left Ventricular dysfunction in 10 (33%) patients. Steroids and intravenous immunoglobulins (IVIG) were administered to 24 (80%) and 12 (41%) patients respectively while 7 (23%) received both. Overall, 20% children expired. During the last five years, 30 and 47 children were diagnosed with KD and VM, respectively. Their comparison with MIS-C group showed lymphopenia, thrombocytosis, and higher CRP as well as more frequent atypical presentation in MIS-C KD group with less coronary involvement. The MIS-C VM was more likely to present with fulminant myocarditis. Conclusions Our MIS-C cohort is younger with higher mortality compared to previous reports. MIS-C is distinct from historic cohorts of KD and VM in both in clinical features and outcomes.

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The Results and Technique of Left Ventricular Endomyocardial Biopsy

Cardiovascular Intervention and Therapeutics Japanese Edition ◽

10.15245/cvit.5.193 ◽

2013 ◽

Vol 5 (3) ◽

pp. 193-197

Author(s):

Emiko Ejima ◽

Koichiroh Matsumura ◽

Fumiyuki Hayashi ◽

Kensaku Shibata ◽

Masahiro Mizobuchi ◽

...

Keyword(s):

Endomyocardial Biopsy ◽

Left Ventricular

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Mechanisms of angina in patients with biopsy-proven viral myocarditis: insights from intracoronary acetylcholine testing

European Heart Journal ◽

10.1093/ehjci/ehaa946.2063 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Seitz ◽

V Martinez Pereyra ◽

A Hubert ◽

K Klingel ◽

R Bekeredjian ◽

...

Keyword(s):

Coronary Arteries ◽

Coronary Spasm ◽

Viral Myocarditis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Funding Source ◽

Pathophysiological Mechanism ◽

Ecg Changes ◽

Ventricular Ejection Fraction ◽

Microvascular Spasm

Abstract Background Patients with myocarditis often present with angina pectoris despite unobstructed coronary arteries. The underlying pathophysiological mechanism of angina in these patients remains to be elucidated. Coronary artery spasm is a well-known cause of angina in patients with unobstructed coronary arteries. In this study, we sought to assess the frequency of coronary vasomotor disorders in patients with biopsy-proven viral myocarditis. Methods In total, 700 consecutive patients who underwent endomyocardial biopsy for suspected myocarditis between 2008 and 2018 were retrospectively screened. Of these patients, viral myocarditis was confirmed in 303 patients defined as histological/immunohistological evidence of myocardial inflammation and presence of viral genome confirmed by PCR. Of these patients, 34 patients had angina despite unobstructed coronary arteries and underwent intracoronary acetylcholine (ACh) provocation testing in search of coronary spasm. Epicardial spasm was defined as acetylcholine-induced reproduction of the patient's symptoms associated with ischemic ECG changes and >90% epicardial vasoconstriction. Microvascular spasm was defined as symptom reproduction and ECG changes in the absence of significant epicardial vasoconstriction. Results Patients were 49±16 years old, 62% were male and left ventricular ejection fraction was 54±16%. Most frequent viruses were parvovirus B19 (PVB19, 59%) and human herpes virus 6 (HHV6, 26%), 2 patients had combined PVB19/HHV6 infection and 3 patients other herpesviruses (CMV, EBV, VZV). Epicardial spasm was observed in 10 patients (29%) during ACh testing and microvascular spasm was found in 11 patients (32%). The rate of coronary spasm (epicardial and microvascular) was higher in the PVB19 subgroup compared to HHV6 (80% vs. 33%, p=0.031). In particular, there was a higher prevalence of microvascular spasm in PVB19 compared to HHV6 (45% vs. 0%, p=0.018). Conclusion We observed a high prevalence of microvascular and epicardial spasm in patients with biopsy-proven viral myocarditis suggesting coronary spasm as a potential underlying mechanism for angina in these patients. Microvascular spasm was most often observed in patients with PVB19-associated myocarditis. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Robert-Bosch-Stiftung; Berthold-Leibinger-Stiftung

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458. Molecular SARS-CoV-2 Testing During the COVID-19 Outbreak: Experiences of a Hospital in Southeast Michigan, USA

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.651 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S296-S297

Author(s):

Trini A Mathew ◽

Jonathan Hopkins ◽

Diane Kamerer ◽

Shagufta N Ali ◽

Daniel Ortiz ◽

...

Keyword(s):

Clinical Features ◽

Diagnostic Testing ◽

Beaumont Hospital ◽

High Capacity ◽

Turnaround Time ◽

Molecular Diagnostic ◽

The Novel ◽

Repeat Testing ◽

Asymptomatic Patients ◽

Novel Coronavirus

Abstract Background The novel Coronavirus SARS CoV-2 (COVID-19) outbreak was complicated by the lack of diagnostic testing kits. In early March 2020, leadership at Beaumont Hospital, Royal Oak Michigan (Beaumont) identified the need to develop high capacity testing modalities with appropriate sensitivity and specificity and rapid turnaround time. We describe the molecular diagnostic testing experience since initial rollout on March 16, 2020 at Beaumont, and results of repeat testing during the peak of the COVID-19 pandemic in MI. Methods Beaumont is an 1100 bed hospital in Southeast MI. In March, testing was initially performed with the EUA Luminex NxTAG CoV Extended Panel until March 28, 2020 when testing was converted to the EUA Cepheid Xpert Xpress SARS-CoV-2 for quicker turnaround times. Each assay was validated with a combination of patient samples and contrived specimens. Results During the initial week of testing there was > 20 % specimen positivity. As the prevalence grew the positivity rate reached 68% by the end of March (Figure 1). Many state and hospital initiatives were implemented during the outbreak, including social distancing and screening of asymptomatic patients to increase case-finding and prevent transmission. We also adopted a process for clinical review of symptomatic patients who initially tested negative for SARS-CoV-2 by a group of infectious disease physicians (Figure 2). This process was expanded to include other trained clinicians who were redeployed from other departments in the hospital. Repeat testing was performed to allow consideration of discontinuation of isolation precautions. During the surge of community cases from March 16 to April 30, 2020, we identified patients with negative PCR tests who subsequently had repeat testing based on clinical evaluation, with 7.1% (39/551) returning positive for SARS- CoV2. Of the patients who expired due to COVID-19 during this period, 4.3% (9/206) initially tested negative before ultimately testing positive. Figure 1 BH RO testing Epicurve Figure 2: Screening tool for repeat COVID19 testing and precautions Conclusion Many state and hospital initiatives helped us flatten the curve for COVID-19. Our hospital testing experience indicate that repeat testing may be warranted for those patients with clinical features suggestive of COVID-19. We will further analyze these cases and clinical features that prompted repeat testing. Disclosures All Authors: No reported disclosures

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Interventional and Surgical Treatments for Pulmonary Arterial Hypertension

Journal of Clinical Medicine ◽

10.3390/jcm10153326 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3326

Author(s):

Tomasz Stącel ◽

Magdalena Latos ◽

Maciej Urlik ◽

Mirosław Nęcki ◽

Remigiusz Antończyk ◽

...

Keyword(s):

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Interdisciplinary Approach ◽

Left Ventricular ◽

Free Survival ◽

Atrial Septostomy ◽

Surgical Options ◽

Pulmonary Arterial ◽

Va Ecmo ◽

Surgical Treatments

Despite significant advancements in pharmacological treatment, interventional and surgical options are still viable treatments for patients with pulmonary arterial hypertension (PAH), particularly idiopathic PAH. Herein, we review the interventional and surgical treatments for PAH. Atrial septostomy and the Potts shunt can be useful bridging tools for lung transplantation (Ltx), which remains the final surgical treatment among patients who are refractory to any other kind of therapy. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) remains the ultimate bridging therapy for patients with severe PAH. More importantly, VA-ECMO plays a crucial role during Ltx and provides necessary left ventricular conditioning during the initial postoperative period. Pulmonary denervation may potentially be a new way to ensure better transplant-free survival among patients with the aforementioned disease. However, high-quality randomized controlled trials are needed. As established, obtaining the Eisenmenger physiology among patients with severe pulmonary hypertension by creating artificial defects is associated with improved survival. However, right-to-left shunting may be harmful after Ltx. Closure of the artificially created defects may carry some risk associated with cardiac surgery, especially among patients with Potts shunts. In conclusion, PAH requires an interdisciplinary approach using pharmacological, interventional, and surgical modalities.

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Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽

10.1177/02676591211033947 ◽

2021 ◽

pp. 026765912110339

Author(s):

Shek-yin Au ◽

Ka-man Fong ◽

Chun-Fung Sunny Tsang ◽

Ka-Chun Alan Chan ◽

Chi Yuen Wong ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Primary Outcome ◽

Left Ventricular ◽

Circulatory Support ◽

Queen Elizabeth Hospital ◽

Intra Aortic Balloon Pump ◽

Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

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The role of inflammation in recent-onset dilated cardiomyopathy

European Heart Journal ◽

10.1093/ehjci/ehaa946.2101 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Chaloupka ◽

J Krejci ◽

H Poloczkova ◽

P Hude ◽

E Ozabalova ◽

...

Keyword(s):

Dilated Cardiomyopathy ◽

Left Ventricular ◽

Pcr Analysis ◽

Myocardial Inflammation ◽

Gene Variants ◽

Absolute Increase ◽

Recent Onset ◽

Cardiotropic Viruses

Abstract Background The aetiology of recent-onset dilated cardiomyopathy (RODCM) includes inflammatory, genetic, toxic and metabolic causes. Delineating the role of inflammation on the genetic background could improve risk stratification. Purpose We aimed to ascertain the role of inflammation evaluated by serum CRP immunohistochemical and PCR analysis of endomyocardial biopsy (EMB) in conjunction with genetic testing in left ventricular reverse remodelling (LVRR) in 12-month follow-up. Methods 83 RODCM patients enrolled in this prospective observational study underwent 12-month echocardiographic follow up whole-exome sequencing, and EMB. Presence of cardiotropic viruses was determined by PCR analysis of the EMB samples. Inflammation was defined according to TIMIC immunohistochemical criteria as the presence of >7 CD3+ lymphocytes/mm2 and/or >14 infiltrating leukocytes (LCA+ cells/mm2). LVRR was defined as an absolute increase in LV ejection fraction > +10% and a relative decrease of LV end-diastolic diameter >−10% at 12 months. Results LVRR occurred in 28 (34%) of all cases. PCR analysis uncovered cardiotropic viruses in 55 (66%) patients, with highest prevalence of parvovirus B19 (47%). (Figure 1) EMB analysis detected inflammation in 28 (34%) cases and inflammation significantly positively predicted LVRR (P=0.019). Sequencing identified disease-related gene variants (ACMG class 3–5) in 45 (54%) patients. Carriers of non-titin gene variants showed a lowest probability of 12-month LVRR (19%) P=0.041. Combination of genetic findings and inflammation did not improve the prediction of LVRR in 12 months. (Table 1) Conclusion Both myocardial inflammation and disease-causing variants can be identified in a large proportion of RODCM cases. Prognostic value of CRP and virus detection is low. Non-titin disease-related variants carriers of are less likely to reach LVRR. In contrast, myocardial inflammation detected by EMB predicts favourable remodelling in 12 months. Figure 1 Funding Acknowledgement Type of funding source: None

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