Fulminant giant-cell myocarditis on mechanical circulatory support: Management and outcomes of a French multicentre cohort

Montero, Santiago; Aïssaoui, Nadia; Tadié, Jean Marc; Bizouarn, Philippe; Scherrer, Vincent; Persichini, Romain; Delmas, Clément; Rolle, F.; Besnier, Emmanuel; Guyader, Alexandre Le; Combes, Alain; Schmidt, Matthieu

doi:10.1016/j.ijcard.2017.10.053

Cited by 40 publications

(31 citation statements)

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“…Thus, the first-line medication is standard heart failure therapy in those with markedly depressed left ventricular function 5 6. In patients with aggressive autoimmune myocarditis, such as giant cell myocarditis or eosinophilic necrotising myocarditis, a combination of high-dose steroids and cyclosporine is recommended, sometimes in combination with muronomab CD3 7–9. Non-steroidal anti-inflammatory drug (NSAID) therapy has been a cornerstone of the symptomatic therapy of uncomplicated pericarditis 10.…”

Section: Introductionmentioning

confidence: 99%

Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up

et al. 2019

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ObjectiveClinical data on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) in myopericarditis are limited. Since NSAIDs are standard therapy in pericarditis, we retrospectively investigated their safety in myopericarditis.MethodsIn a retrospective case-control study, we identified 60 patients with myopericarditis from September 2010 to August 2017. Diagnosis was based on clinical criteria, elevated high-sensitivity troponin T and cardiac magnetic resonance imaging (CMR). All patients received standard heart failure therapy if indicated. Twenty-nine patients (62%) received NSAIDs (acetylsalicylic acid: n=7, average daily dose =1300 mg or ibuprofen: n=22, average daily dose =1500 mg) for an average duration of 4 weeks. To create two cohorts with similar baseline conditions, 15 patients were excluded. Three months after diagnosis, 29 patients were re-evaluated by CMR to measure late gadolinium enhancement (LGE).ResultsBaseline characteristics of those treated with or without NSAIDs were similar. Mean age was 34 (±13) years, 6 (13%) were women. Mean left ventricular ejection fraction (LVEF) was 56% (±5). 82 % of the patients (14 of 17) treated with NSAIDs experienced a decrease in LGE at 3 months, while it was only 58 % (7 of 12) of those without NSAIDs (p=0.15). At 12-month follow-up, one of the patients treated without NSAIDs experienced polymorphic ventricular tachycardia (VT) with cardiac arrest, while one of the patients with NSAIDs experienced non-sustained VT.ConclusionsThis is the first case-control study demonstrating that NSAIDs are safe in patients with myopericarditis and preserved LVEF. Our data suggest that this drug class should be tested prospectively in a large randomised clinical trial.

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Section: Introductionmentioning

confidence: 99%

Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up

et al. 2019

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“…There are a variety of temporary and durable options for MCS in the management of GCM. Of the temporary options, VA ECMO has been considered favorably [16] in the initial management of patients with GCM presenting in cardiogenic shock given its ability to provide temporary stabilization until a diagnosis is made or the need for durable MCS is determined [17]. With VA ECMO support, there is a need to unload the ventricle with venting or Impella, which has been shown to have disease-modifying effects [18,19].…”

Section: Discussion Of Clinical Significancementioning

confidence: 99%

“…Another reported benefit [16] of MCS is its ability to support the ventricle if it becomes irritated after EMB, the gold-standard [23] for GCM diagnosis. Early biopsy is critical for patients with suspected GCM, given that rates of transplant and death have been reported [17] as high as 80% to 100% in patients who do not receive a biopsy. Patients often require repetitive biopsies when the results are inconclusive or disease recurrence is suspected [24].…”

Section: Discussion Of Clinical Significancementioning

confidence: 99%

“…Arrhythmias were detected in 57.1% (24/42) of patients, with complete atrioventricular (AV) block and ventricular tachycardia being the most common. Of note, patients who received MCS + IS had a significantly higher left ventricular ejection fraction (LVEF) at presentation compared to patients who received MCS alone (28% (20-30) vs. 17% (13)(14)(15)(16)(17)(18)(19)(20), p = 0.03). The final diagnosis of GCM was made using endomyocardial biopsy in 72.1% (31/43) of cases, left ventricular apical core biopsy in 23.3% (10/43) of cases, and biopsy of the explanted heart in 2.3% (1/43) of cases.…”

Section: Baseline Characteristicsmentioning

confidence: 99%

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Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review

Patel

Saxena

Wood

et al. 2020

JCM

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Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32–57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58–255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS.

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“…Выживаемость больных ФМ после трансплантации сердца сопоставима с выживаемостью пациентов с другими причинами СН, хотя в нескольких исследованиях отмечена высокая частота рецидива заболевания, особенно у пациентов с гигантоклеточным миокардитом [21]. Таблица 1.…”

Section: Discussionunclassified

The Case of Fulminant Myocarditis

et al. 2019

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Fulminant myocarditis (FM) is a severe form of inflammatory myocardial injury rapidly developing as acute heart failure, cardiogenic shock, or life-threatening disturbances of cardiac rhythm. FM requires intensive treatment including drug therapy, mechanical circulatory support, and in some cases – heart transplantation. Echocardiography can be used as a screening method of diagnostics. Magnetic resonance imaging of the heart often cannot be performed because of hemodynamic instability of a patient, therefore endomyocardial biopsy with histological and immunohistochemical studies as well as molecular-genetic analysis of obtained samples is required for final diagnosis. Prognosis of the disease is determined by histological picture. In most cases, after cessation of acute stage of the inflammatory process, FM has a favorable long-term prognosis. In this article we present a clinical case of FM and review of current literature on diagnosis and treatment of this disease.

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Fulminant giant-cell myocarditis on mechanical circulatory support: Management and outcomes of a French multicentre cohort

Abstract: Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option.

Cited by 40 publications

References 41 publications

Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up

Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up

Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review

The Case of Fulminant Myocarditis

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