Paediatric Inflammatory Multisystem Syndrome Temporally Associated with Sars-Cov-2: A Review and Our Experience in a Secondary Hospital in Spain

Acute Phase Reactants ◽

Secondary Hospital

Introduction: Paediatric multisystem inflammation syndrome temporally associated with SARS-COV-2 (PIMS-TS was described in 2020 as an increased incidence of paediatric patients with cardiogenic shock and acute myocarditis associated with SARS-COV2. This disease has similarities and can manifest as Kawasaki Disease (KD). The aim of the study was to document the cardiovascular characteristics of the novel multisystem inflammatory syndrome in children and to share our experience. Methods: A descriptive study is presented including children with diagnosis of PIMS- TS at a secondary hospital. Children 0 to 15 years of age admitted to a hospital between from May 2020 to May 2021 were included and the data, including demography, clinical status, biochemical markers, echocardiography findings, treatment and evolution, were extracted from the clinical history of the patients. Results: 7 children were included from a secondary hospital. The mean age was 8 years and 71% were boys. The most common cardiovascular complications were cardiovascular shock with hypotension and the reduction in over a half of the patients in the left ventricular ejection fraction was reported. It was observed a high elevation of acute phase reactants at the admission. In 2 children were found coronary alterations. Polymerase chain reaction (PCR) for SARS-COV-2 was positive in 28% whereas immunoglobulin G (IgG) was positive in 100% cases. Conclusion: Covid-19 disease is asymptomatic in children in most cases but cardiovascular involvement is common if PIMS-TS is presented. Despite the need of intensive care support, mortality is uncommon and our study shows that these patients can be treated in a hospital with Paediatric Intensive Critical Unit level 2 benefiting from combined, specific treatment.

Are high NT-proBNP levels more related to inflammation than to left ventricular systolic dysfunction in acute myocarditis?

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.189 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

B Sara ◽

JJ Monteiro ◽

P Carvalho ◽

C Ribeiro Carvalho ◽

J Chemba ◽

...

Keyword(s):

Ejection Fraction ◽

Plasma Levels ◽

Left Ventricular Systolic Dysfunction ◽

Small Sample Size ◽

Acute Myocarditis ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Small Sample ◽

Ventricular Ejection Fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Plasma levels and N-terminal pro B-type natriuretic peptide (NT- proBNP), a cardiac neurohormone released in response to increased ventricular stress, represent an important predictor of clinical outcomes and left ventricular (LV) dysfunction; Although, its diagnostic and prognostic role in patients with acute myocarditis is not completely established; Our aim was to evaluate the relationship of BNP levels and LV ejection fraction (LVEF) in patients with myocarditis; Methods Data from patients (pts) discharged with the diagnosis of myocarditis, from 2008 and 2018 were retrospectively analysed. Results 62 pts were included. Mean age was 39.7 17 years and 89% (58 patients) were men. Plasma levels of NT-proBNP measured at admission ranged from 24 to 3110 pg/mL (median 514, IQR 947), and exceeded upper normal levels in 51 pts (82%). This values positively correlated with C- reactive protein (CRP) (p= 0.005, r = 0.36), leucocytes (p = 0.03, r= 0.37) and neutrophil-to-lymphocyte ratio (p= 0.05, r= 0.35), but not with left ventricular ejection fraction (LVEF) (p= 0.829). Higher levels of BNP were associated with higher troponin peak levels but not with increased mortality (p = 0.811), need of inotropic support (p= 0.059) or arrhythmic events (p= 0.130). Inflammatory parameters were significantly increased when BNP> 514 pg/mL vs BNP <514 pg/mL (CRP 7.2 vs 4 mg/dL, p= 0.008). This relationship was maintained at BNP > 900. LVEF was comparable in both groups (p = 0.938); In this population, the magnitude of recovery of the NT- proBNP values (variation between NT-proBNP at admission and discharge) strongly correlated with the magnitude of the inflammatory markers at admission (all p < 0,005) Conclusion In patients with acute myocarditis, there is a significant relationship between NT-proBNP levels and inflammation (as measured by leucocytes, NLR or CRP), but not with LVEF; Despite the limitation of a small sample size, we could hypothesize that NTproBNP in this subset of patients appears to be regulated not only by hemodynamic changes but also by the underlying systemic inflammatory process and, therefore, it interpretation should take that into account;

His-optimized cardiac resynchronization therapy in a patient with heart failure and right bundle branch block: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab277 ◽

2021 ◽

Vol 5 (8) ◽

Author(s):

Dmytro Volkov ◽

Dmytro Lopin ◽

Stanislav Rybchynskyi ◽

Dmytro Skoryi

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Right Bundle Branch Block ◽

Clinical Status ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Bundle Branch Block ◽

Ventricular Ejection Fraction

Abstract Background Cardiac resynchronization therapy (CRT) is an option for treatment for chronic heart failure (HF) associated with left bundle branch block (LBBB). Patients with HF and right bundle branch block (RBBB) have potentially worse outcomes in comparison to LBBB. Traditional CRT in RBBB can increase mortality and HF deterioration rates over native disease progression. His bundle pacing may improve the results of CRT in those patients. Furthermore, atrioventricular node ablation (AVNA) for rate control in atrial fibrillation (AF) can be challenging in patients with previously implanted leads in His region. Case summary We report the case of 74-year-old gentleman with a 5-year history of HF, permanent AF with a rapid ventricular response, and RBBB. He was admitted to the hospital with complaints of severe weakness and shortness of breath. Left ventricular ejection fraction (LVEF) was decreased (41%), right ventricle (RV) was dilated (41 mm), and QRS was prolonged (200 ms) with RBBB morphology. The patient underwent His-optimized CRT with further left-sided AVNA. As a result, LVEF increased to 51%, RV dimensions decreased to 35 mm with an improvement of the clinical status during a 6-month follow-up. Discussion Patients with AF, RBBB, and HF represent the least evaluated clinical subgroup of individuals with less beneficial clinical outcomes according to CRT studies. Achieving the most effective resynchronization could require pacing fusion from sites beyond traditional with the intention to recruit intrinsic conduction pathways. This approach can be favourable for reducing RV dilatation, improving LVEF, and maximizing electrical resynchronization.

The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

Diagnostics ◽

10.3390/diagnostics12010156 ◽

2022 ◽

Vol 12 (1) ◽

pp. 156

Author(s):

Jakub Lagan ◽

Christien Fortune ◽

David Hutchings ◽

Joshua Bradley ◽

Josephine H. Naish ◽

...

Keyword(s):

Magnetic Resonance ◽

Volume Fraction ◽

Acute Myocarditis ◽

Multivariable Analysis ◽

Left Ventricular ◽

Parametric Mapping ◽

The Impact

Cardiovascular magnetic resonance (CMR) is used to investigate suspected acute myocarditis, however most supporting data is retrospective and few studies have included parametric mapping. We aimed to investigate the utility of contemporary multiparametric CMR in a large prospective cohort of patients with suspected acute myocarditis, the impact of real-world variations in practice, the relationship between clinical characteristics and CMR findings and factors predicting outcome. 540 consecutive patients we recruited. The 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation were followed-up for 674 (504–915) days. 39 patients underwent follow-up CMR at 189 (166–209) days. CMR provided a positive diagnosis in 72% of patients, including myocarditis (40%) and myocardial infarction (11%). In multivariable analysis, male sex and shorter presentation-to-scan interval were associated with a diagnosis of myocarditis. Presentation with heart failure (HF) was associated with lower left ventricular ejection fraction (LVEF), higher LGE burden and higher extracellular volume fraction. Lower baseline LVEF predicted follow-up LV dysfunction. Multiparametric CMR has a high diagnostic yield in suspected acute myocarditis. CMR should be performed early and include parametric mapping. Patients presenting with HF and reduced LVEF require closer follow-up while those with normal CMR may not require it.

Myocarditis and pericarditis

10.1093/med/9780199687039.003.0058_update_001 ◽

2017 ◽

Author(s):

Michel Noutsias ◽

Bernhard Maisch

Keyword(s):

Dilated Cardiomyopathy ◽

Clinical Management ◽

Acute Myocarditis ◽

Left Ventricular ◽

Histological Evaluation ◽

Prognostic Impact ◽

Inflammatory Cardiomyopathy ◽

Cardioverter Defibrillator

Transition of acute myocarditis to dilated cardiomyopathy occurs in approximately 20% of patients within a follow-up period of 33 months. Recent research has revealed the adverse prognostic impact of several clinical parameters for this scenario. Acute myocarditis and its sequelae dilated cardiomyopathy and inflammatory cardiomyopathy are often caused by viral infections. Histological evaluation of endomyocardial biopsies is critical for the diagnosis of the cardiomyopathy entity and for the clinical management of around 20% of the patients. Additionally, contemporary diagnostic procedures of endomyocardial biopsies are indispensable for the selection of inflammatory cardiomyopathy patients who will likely benefit from immunosuppression or antiviral (interferon) treatment. Immunoadsorption, with subsequent immunoglobulin substitution, is a further promising immunomodulatory treatment option for dilated cardiomyopathy patients, targeting primarily the anticardiac autoantibodies. Cardiac magnetic resonance has emerged as a valuable diagnostic approach for myocarditis and pericarditis. Myocardial late gadolinium enhancement has been associated with adverse outcome and sudden cardiac death. Bridging of the first 3 months with a wearable cardioverter–defibrillator, until a definitive decision on the implantation of an implantable cardioverter–defibrillator, is a growingly recognized cornerstone in the clinical management of patients with acute myocarditis with depressed left ventricular ejection fraction of <40% and new-onset dilated cardiomyopathy, respectively. Acute pericarditis is labelled idiopathic or suspected viral without adequate proof of the respective aetiology. Non-steroidal anti-inflammatory drugs and colchicine are proven and safe therapeutic mainstays for pericarditis, including the first attack. Pericardiocentesis is a lifesaving treatment of cardiac tamponade. Pericardioscopy and epicardial biopsies can contribute to the aetiological differentiation of pericardial effusions.

Transoesophageal echocardiography-guided ‘primary’ valve-in-valve technique in cardiogenic shock: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab229 ◽

2021 ◽

Vol 5 (7) ◽

Author(s):

Vincenzo Polizzi ◽

Joseph Cosma ◽

Antonio Cammardella ◽

Federico Ranocchi ◽

Francesco Musumeci

Keyword(s):

Cardiogenic Shock ◽

Ct Scan ◽

Acute Myocarditis ◽

Transoesophageal Echocardiography ◽

Left Ventricular ◽

Haemodynamic Instability ◽

Essential Information ◽

Valve In Valve

Abstract Background Transcatheter aortic valve implantation inside a previously implanted bioprosthesis is an alternative treatment for patients with degenerated surgical aortic bioprosthesis (AB) at high surgical risk. Pre-operative computed tomography (CT) scan provides essential information to the procedure planning, although in case of acute presentation it is not always feasible. Case summary A 32-year-old man with history of surgical treatment of aortic coarctation and Bio-Bentall procedure was transferred to our department in cardiogenic shock with a suspected diagnosis of acute myocarditis. A transthoracic echocardiogram (TTE) revealed a severely impaired biventricular function and AB degeneration causing severe stenosis. It was decided to undertake an urgent trans-apical valve-in-valve (ViV) procedure. Due to haemodynamic instability, a preoperative CT scan was not performed and transoesophageal echocardiography (TOE) was the main intraprocedural guiding imaging technique. Neither intraprocedural nor periprocedural complications occurred. Serial post-procedural TTE exams showed good functioning of the bioprosthesis and progressive improvement of left ventricular ejection fraction. Patient was discharged from the hospital 8 days after the intervention. Discussion A patient with cardiogenic shock due to severe degeneration of the AB was treated with urgent transapical ViV procedure. In this case, where urgent ViV technique was needed, TOE appeared to be a crucial alternative to CT scan and allowed us to perform a successful procedure.

Myocarditis and pericarditis

10.1093/med/9780199687039.003.0058 ◽

2015 ◽

Author(s):

Michel Noutsias ◽

Bernhard Maisch

Keyword(s):

Dilated Cardiomyopathy ◽

Clinical Management ◽

Acute Myocarditis ◽

Left Ventricular ◽

Histological Evaluation ◽

Prognostic Impact ◽

Inflammatory Cardiomyopathy ◽

Cardioverter Defibrillator

Transition of acute myocarditis to dilated cardiomyopathy occurs in approximately 20% of patients within a follow-up period of 33 months. Recent research has revealed the adverse prognostic impact of several clinical parameters for this scenario. Acute myocarditis and its sequelae dilated cardiomyopathy and inflammatory cardiomyopathy are often caused by viral infections. Histological evaluation of endomyocardial biopsies is critical for the diagnosis of the cardiomyopathy entity and for the clinical management of around 20% of the patients. Additionally, contemporary diagnostic procedures of endomyocardial biopsies are indispensable for the selection of inflammatory cardiomyopathy patients who will likely benefit from immunosuppression or antiviral (interferon) treatment. Immunoadsorption, with subsequent immunoglobulin substitution, is a further promising immunomodulatory treatment option for dilated cardiomyopathy patients, targeting primarily the anticardiac autoantibodies. Cardiac magnetic resonance has emerged as a valuable diagnostic approach for myocarditis and pericarditis. Myocardial late gadolinium enhancement has been associated with adverse outcome and sudden cardiac death. Bridging of the first 3–6 months with a wearable cardioverter–defibrillator, until a definitive decision on the implantation of an implantable cardioverter–defibrillator, is a growingly recognized cornerstone in the clinical management of patients with acute myocarditis with depressed left ventricular ejection fraction of <40% and new-onset dilated cardiomyopathy, respectively. Acute pericarditis is labelled idiopathic or suspected viral without adequate proof of the respective aetiology. Non-steroidal anti-inflammatory drugs and colchicine are proven and safe therapeutic mainstays for pericarditis, including the first attack. Pericardiocentesis is a lifesaving treatment of cardiac tamponade. Pericardioscopy and epicardial biopsies can contribute to the aetiological differentiation of pericardial effusions.

Abstract 5936: Can Apoptosis Predict Functional Recovery in Acute Myocarditis?

Circulation ◽

10.1161/circ.118.suppl_18.s_1033-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Antonio Abbate ◽

Gianfranco Sinagra ◽

Rossana Bussani ◽

Nicholas N Hoke ◽

Stefano Toldo ◽

...

Keyword(s):

Functional Recovery ◽

Cardiac Dysfunction ◽

Acute Myocarditis ◽

Left Ventricular ◽

Causal Association ◽

Double Positive ◽

Cytokeratin 18 ◽

Ventricular Ejection Fraction

Background. Acute myocarditis is characterized by acute cardiac dysfunction followed by a variable recovery over time. Recent data have shown the presence of apoptosis in acute myocarditis. We hypothesized that the presence and extent of apoptosis evaluated at endomyocardial biopsy (EMB) could predict functional recovery in patients with acute myocarditis, with more apoptosis predicting less recovery. Methods. Sixteen patients with acute myocarditis were studied with EMB. Baseline and follow up echocardiography was obtained in all cases. The patients were retrospectively divided in 2 groups according to the final left ventricular ejection fraction (LVEF): LVEF>40% [recovery] and LVEF≤40% [no recovery]. Co-staining for DNA fragmentation (TUNEL) and caspase-cleaved cytokeratin-18 (CytoDeath) were performed to quantify the cardiomyocyte apoptosis in EMB specimens. Four subjects dying of non-cardiac causes were selected as control hearts at time of autopsy. Results. Six patients showed functional recovery (38%) while 8 did not (62%). The apoptotic rate (AR, expressed as % of double positive cardiomyocytes on total number per field) was significantly higher in the hearts of patients with acute myocarditis (1.1%[0.7–2.2] vs 0.01%[0.01–0.01] in control hearts, p<0.001). Unexpectedly, patients with functional recovery had a significantly higher AR than patients without recovery (3.2%[1.1–8.0] vs 0.5%[0.3–1.0], p=0.001), and the AR correlated with follow-up LVEF (R=+0.54, p=0.030). Six of the 8 patients (75%) with AR above average showed functional recovery vs 0 of the 8 patients (0%) with AR below average (p=0.007). Conclusions. This study surprisingly shows that the presence of greater apoptosis at EBM in patients with acute myocarditis predicts functional recovery at 12 months. Whether this represents a true cause-effect association or it simply represents a non-causal association remains unclear and warrants further studies.

Association of Physical Activity and Prognostic Parameters in Elderly Patients With Heart Failure

Journal of Aging and Physical Activity ◽

10.1123/japa.19.1.1 ◽

2011 ◽

Vol 19 (1) ◽

pp. 1-15 ◽

Cited By ~ 10

Author(s):

Melissa Jehn ◽

Arno Schmidt-Trucksäss ◽

Henner Hanssen ◽

Tibor Schuster ◽

Martin Halle ◽

...

Keyword(s):

Physical Activity ◽

Heart Failure ◽

Nyha Class ◽

Clinical Status ◽

Heart Association ◽

Left Ventricular ◽

Functional Class ◽

Patients With Heart Failure

Objective:Assessment of habitual physical activity (PA) in patients with heart failure.Methods:This study included 50 patients with heart failure (61.9 ± 4.0 yr). Seven days of PA were assessed by questionnaire (AQ), pedometer, and accelerometer and correlated with prognostic markers including VO2peak, percent left-ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide, and New York Heart Association (NYHA) functional class.Results:Accelerometry showed a stronger correlation with VO2peak and NYHA class (R = .73 and R = −.68; p < .001) than AQ (R = .58 and R = −.65; p < .001) or pedometer (R = .52 and R = −.50; p < .001). In the multivariable regression model accelerometry was the only consistent independent predictor of VO2peak (p = .002). Moreover, when its accuracy of prediction was tested, 59% of NYHA I and 95% of NYHA III patients were correctly classified into their assigned NYHA classes based on their accelerometer activity.Conclusion:PA assessed by accelerometer is significantly associated with exercise capacity in patients with heart failure and is predictive of disease severity. The data suggests that PA monitoring can aid in evaluating clinical status.

New and old echographic parameters in heart failure

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa142 ◽

2020 ◽

Vol 22 (Supplement_L) ◽

pp. L86-L92

Author(s):

Giovanni La Canna ◽

Iside Scarfo’

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Specific Treatment ◽

Left Ventricular ◽

New Information ◽

Appropriate Treatment ◽

Prognostic Stratification ◽

Line Technology

Abstract Echography (ECHO) is a first-line technology for diagnostic evaluation and prognostic stratification of patients with heart failure (HF). Recognizing specific diseases or conditions amenable to specific treatment is a crucial step in the work-up of patients with HF. Left ventricular ejection fraction (EF) measurement, despite its pathophysiological and methodological limitations, is the primary parameter for the HF classification, incorporating forms with reduced, moderately reduced, and preserved ejection fraction. The cardiac filling parameters could characterize the haemodynamic profile of the various forms of HF and guide different clinical therapeutic strategies. Besides the conventional parameters, widely validated by the clinical practice (old parameters), ECHO provides new information on cardiac function (deformation index), which prospectively could refine our phenotypic classification, beyond EF, thus opening new prospects in the pre-clinical identification, and in the selection of the appropriate treatment for HF patients Stemming from the recent technologic improvements, it is possible to analyse conventional parameters with innovative and automatic approaches, which are quickly available, and able to open new perspectives in the treatment of patients with HF.