Dynamic changes of heart structural and functional condition in patients with acute myocarditis
Keywords:myocarditis, magnetic-resonance imaging
Diagnosis and prognosis of myocarditis course, which is an inflammatory heart muscle disease, has been and remains one of the most urgent, complex and unresolved problem in modern cardiology.
The purpose of the study – to investigate the dynamic changes in the structural and functional heart state in patients with acute myocarditis and reduced left ventricular ejection fraction.
Materials and methods. In total, 74 patients with clinically suspected acute myocarditis (AM) with reduced left ventricular (LV) ejection fraction (EF) ≤40 % and NYHA heart failure (HF) functional class II or higher were examined three times: in the first month of myocarditis debut, after 6 and 12 months of observation. All the patients underwent echocardiography and speckle-tracking echocardiography, Holter electrocardiogram monitoring and cardiac magnetic resonance imaging (MRI).
Results. It was found that the debut of AM was characterized by the presence of active inflammatory process according to the cardiac MRI - edema and hyperemia of the myocardium were detected in 54.0 % and 70.2 % of cases, respectively, followed by LV dilation and systolic dysfunction as well as by a significant decrease in longitudinal and circumferential LV global systolic strain. After 12 months of observation, there was a significant increase in LV EF, decrease in end-diastolic volume index and an improvement in the parameters of longitudinal and circumferntial LV systolic strain by 30.8 % and 36.8 %, respectively, (P < 0.01), the frequency of active inflammatory changes in the myocardium was significantly reduced, herewith in 41.8 % of cases, delayed enhancement was noted, indicating fibrotic changes in the myocardium. The presence of delayed enhancement in cardiac MRI after 12 months since myocarditis onset was correlated with the presence of unstable ventricular tachycardia episodes (r = 0.62; P < 0.02) and with the frequency of ventricular extrasystoles (r = 0.53; P < 0.05). A significant influence of fibrotic changes in the myocardium on the presence of unstable ventricular tachycardia episodes in 12 months after the disease onset was confirmed by determining Fisher's exact test, its value was: P = 0.016 (P < 0.05).
Conclusions. It was established that the debut of myocarditis was characterized by a significant violation of the structural and functional heart state: an active inflammatory process in the myocardium causedLV dilatation and contractile dysfunction. After 12 months, a decrease in detection of active inflammatory myocardial changes followed by regression ofLV dilation and its contractile function improvement was observed. It was proved that the presence of fibrotic changes in the myocardium in patients with myocarditis was associated with the persistence of ventricular rhythm disorders.
Biestroek, P. S., Beek, A. M., Germans, T., Niessen, H., & Van Rossum, A. (2015). Diagnosis of myocarditis: current state and future perspectives. Int. J. Cardiol., 191, 211–219. doi: 10.1016/j.ijcard.2015.05.008
Caforio, A. L. P., Pankuweit, S., Arbustini, E., Basso, C., Gimeno-Blanes, J., Felix, S. B., et al. (2013) Current state of knowledge on aetiology, diagnosis, management and therapy of myocarditis: a position statement of the ESC Working group on myocardial and pericardial diseases. Eur. Heart J., 34(33), 2636–2648. doi: 10.1093/eurheartj/eht210
Knowlton, K. U. (2017). Myocarditis. An intersection between genetic and acquired causes of human cardiomyopathy. J Am Coll Cardiol., 69(13), 1666–1668. doi: 10.1016/j.jacc.2017.02.008
Lewek, J., Kaczmarec, K., Cygankiewicz, I., Wranicz, J. K., & Plaszynski, P. (2014) Inflammation and arrhythmias: potential mechanisms and clinical implications. Expert. Rev. Cardiovasc. Ther., 12(9), 1077–85. doi: 10.1586/14779072.2014.942286
Fung, G., Luo, H., Qiu, Y., Yang, D., & McManus, B. (2016). Myocarditis. Circ. Res., 118(3), 496–514. doi: 10.1161/CIRCRESAHA.115.306573
Mahrholdt, H., & Greuilich, S. (2017). Prognosis in myocarditis. JACC, 70(16), 1988–1990. doi: 10.1016/j.jacc.2017.08.062
Friedrich, M. G., Sechtem, U., Schultz-Menger, J., Holmvang, G., Alakija, P., Cooper, L. T., et al. (2009). Cardiovascular magnetic resonance in myocarditis: a Journal of the American College of Cardiology White Paper. J Am Coll Cardiol, 53(17), 1475–1487. doi: 10.1016/j.jacc.2009.02.007
Sinagra, G. F., Anzini, M., Pereira, N. L., Bussani, R., Finochiarro, G., Bartunek, J., & Merlo, M (2016). Myocarditis in clinical practice. Mayo Clin. Proc., 91(9), 1256–1266. doi: 10.1016/j.mayocp.2016.05.013
Grani, C., Eichhorn, L., Biere, L., Murthy, V. L., Agarwal, V., Kaneko, K., et al. (2017). Prognostic value of cardiac magnetic resonance tissue characterization in risk stratifying patients with suspected myocarditis. J Am Coll Cardiol, 70(16), 1964–1976. doi: 10.1016/j.jacc.2017.08.050
Lurz, P., Leucke, C., Eitel, I., Föhrenbach, F., Frank, C., Grothoff, M., et al. (2016). Comprehensive cardiac magnetic resonance imaging in patients with suspected myocarditis: the myoRacer-Trial. J Am Coll Cardiol., 67(15), 1800–1811. doi: 10.1016/j.jacc.2016.02.013
Hsiao, J. F., Koshino, Y., Bonnichsen, C. R., Yu, Y., Miller, F. A. Jr, Pellikka, P. A., et al. (2013). Speckle tracking echocardiography in acute myocarditis. Int. J Cardiovasc. Imaging., 29(2), 275–284. doi: 10.1007/s10554-012-0085-6
Sturmberger, T., Niel, J., Aichinger, J., & Ebner, C. (2016). Acute myocarditis with normal wall motion detected with 2D speckle tracking echocardiography. Echo Res. Pract., 3(1), K15–19. doi: 10.1530/ERP-16-0013
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J. S., et al. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J., 37(27), 2129–2200. doi: 10.1093/eurheartj/ehw128
Lang, R., Badano, L. P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L., et al. (2015) Recommendations for cardiac chamber quantification in adults: an update from the American Society of echocardiography and European Asssociation of cardiovascular imaging. J. Am. Soc. Echocardiogr., 28(1), 1–39.e14. doi: 10.1016/j.echo.2014.10.003
Leitman, M., Verd, Z., Toymkin, V., Macogon, B., Moravsky, G., Peleg, E., Copel, L. (2018). Speckle tracking imaging in inflammatory heart diseases. Int. J. of Cardiovasc. Imaging, 34(5), 787–792. doi: 10.1007/s10554-017-1284-y
How to Cite
LicenseAuthors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access)