Pediatric Cardiology

, Volume 31, Issue 2, pp 222–228

Pediatric Patients Hospitalized with Myocarditis: A Multi-Institutional Analysis

  • Darren Klugman
  • John T. Berger
  • Craig A. Sable
  • Jianping He
  • Sachin G. Khandelwal
  • Anthony D. Slonim
Original Article

Abstract

The objective of this study was to identify the patient, institutional, and utilization characteristics associated with outcome in hospitalized pediatric patients with myocarditis. This was a nonconcurrent cohort study of all consecutive pediatric discharges from the 35 academic children’s hospitals that are members of the Pediatric Health Information System (PHIS): patients from birth through age 21 years discharged from participating hospitals between January 1, 2005, and December 31, 2005. Patient-level, institution-level, and utilization variables were examined. A total of 427,615 patients were discharged, and 216 (0.05%) were diagnosed with myocarditis. Common etiologies were idiopathic (82%), related to other diseases (6%), and bacterial or viral (3%). Myocarditis patients required considerable support including intravenous immunoglobulin (IVIG; 49.1%), milrinone (45%), epinephrine (35%), mechanical ventilation (25%), extracorporeal membrane oxygenation (7%), and cardiac transplantation (5%). Even in patients with extreme illness scores, IVIG use did not impact survival (P = 0.67). Overall survival of myocarditis patients was 92%. Myocarditis patients who died presented with a higher severity of illness and required frequent use of extracorporeal membrane oxygenation and other ICU therapies. In conclusion, pediatric patients with myocarditis have considerable variability in their presentations and outcomes, use more resources, and die more often than children with other diagnoses. Attempts at using characteristics that uniformly predict illness severity or survival were not successful. Despite increased use in the sickest patients, IVIG conferred no survival advantage.

Keywords

Myocarditis Survival Children Severity of illness Intensive care unit Extracorporeal membrane oxygenation Intravenous immunoglobulin 

References

  1. 1.
    Amabile N, Fraisse A, Bouvenot J, Chetaille P, Ovaert C (2006) Outcome of acute fulminant myocarditis in children. Heart 92:1269–1273CrossRefPubMedGoogle Scholar
  2. 2.
    Aretz HT, Billingham ME, Edwards WD, Factor SM, Fallon JT, Fenoglio JJ Jr, Olsen EG, Schoen FJ (1987) Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1:3–14PubMedGoogle Scholar
  3. 3.
    Batra AS, Lewis AB (2001) Acute myocarditis. Curr Opin Pediatr 13:234–239CrossRefPubMedGoogle Scholar
  4. 4.
    Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, Chu SH, Ko WJ (1999) Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 68:2220–2224CrossRefPubMedGoogle Scholar
  5. 5.
    Corrado D, Basso C, Thiene G (2001) Sudden cardiac death in young people with apparently normal heart. Cardiovasc Res 50:399–408CrossRefPubMedGoogle Scholar
  6. 6.
    Dec GW Jr, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA (1985) Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome. N Engl J Med 312:885–890PubMedGoogle Scholar
  7. 7.
    Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL, Takahashi M, Baker AL, Perez-Atayde AR, Newburger JW (1994) Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 89:252–257PubMedGoogle Scholar
  8. 8.
    Duncan BW, Bohn DJ, Atz AM, French JW, Laussen PC, Wessel DL (2001) Mechanical circulatory support for the treatment of children with acute fulminant myocarditis. J Thorac Cardiovasc Surg 122:440–448CrossRefPubMedGoogle Scholar
  9. 9.
    English RF, Janosky JE, Ettedgui JA, Webber SA (2004) Outcomes for children with acute myocarditis. Cardiol Young 14:488–493CrossRefPubMedGoogle Scholar
  10. 10.
    Feldman AM, McNamara D (2000) Myocarditis. N Engl J Med 343:1388–1398CrossRefPubMedGoogle Scholar
  11. 11.
    Felker GM, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Baughman KL, Hare JM (2000) Echocardiographic findings in fulminant and acute myocarditis. J Am Coll Cardiol 36:227–232CrossRefPubMedGoogle Scholar
  12. 12.
    Fenoglio JJ Jr, Ursell PC, Kellogg CF, Drusin RE, Weiss MB (1983) Diagnosis and classification of myocarditis by endomyocardial biopsy. N Engl J Med 308:12–18PubMedGoogle Scholar
  13. 13.
    Friedrich MG, Strohm O, Schulz-Menger J, Marciniak H, Luft FC, Dietz R (1998) Contrast media-enhanced magnetic resonance imaging visualizes myocardial changes in the course of viral myocarditis. Circulation 97:1802–1809PubMedGoogle Scholar
  14. 14.
    Gagliardi MG, Bevilacqua M, Bassano C, Leonardi B, Boldrini R, Camassei FD, Fierabracci A, Ugazio AG, Bottazzo GF (2004) Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart 90:1167–1171CrossRefPubMedGoogle Scholar
  15. 15.
    Hetzer R, Potapov EV, Stiller B, Weng Y, Hubler M, Lemmer J, Alexi-Meskishvili V, Redlin M, Merkle F, Kaufmann F, Hennig E (2006) Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in pediatric patients. Ann Thorac Surg 82:917–924 (discussion 924–915)CrossRefPubMedGoogle Scholar
  16. 16.
    Kleinert S, Weintraub RG, Wilkinson JL, Chow CW (1997) Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression. J Heart Lung Transpl 16:1248–1254Google Scholar
  17. 17.
    Kuhn B, Shapiro ED, Walls TA, Friedman AH (2004) Predictors of outcome of myocarditis. Pediatr Cardiol 25:379–384CrossRefPubMedGoogle Scholar
  18. 18.
    Lee KJ, McCrindle BW, Bohn DJ, Wilson GJ, Taylor GP, Freedom RM, Smallhorn JF, Benson LN (1999) Clinical outcomes of acute myocarditis in childhood. Heart 82:226–233PubMedGoogle Scholar
  19. 19.
    Lipshultz SE, Sleeper LA, Towbin JA, Lowe AM, Orav EJ, Cox GF, Lurie PR, McCoy KL, McDonald MA, Messere JE, Colan SD (2003) The incidence of pediatric cardiomyopathy in two regions of the United States. N Engl J Med 348:1647–1655CrossRefPubMedGoogle Scholar
  20. 20.
    Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiadis A, Vogelsberg H, Fritz P, Klingel K, Kandolf R, Sechtem U (2004) Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation 109:1250–1258CrossRefPubMedGoogle Scholar
  21. 21.
    Mason JW, O’Connell JB, Herskowitz A, Rose NR, McManus BM, Billingham ME, Moon TE (1995) A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 333:269–275CrossRefPubMedGoogle Scholar
  22. 22.
    McCarthy RE 3rd, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM, Baughman KL (2000) Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 342:690–695CrossRefPubMedGoogle Scholar
  23. 23.
    Nugent AW, Daubeney PE, Chondros P, Carlin JB, Cheung M, Wilkinson LC, Davis AM, Kahler SG, Chow CW, Wilkinson JL, Weintraub RG (2003) The epidemiology of childhood cardiomyopathy in Australia. N Engl J Med 348:1639–1646CrossRefPubMedGoogle Scholar
  24. 24.
    Phillips M, Robinowitz M, Higgins JR, Boran KJ, Reed T, Virmani R (1986) Sudden cardiac death in Air Force recruits. A 20-year review. JAMA 256:2696–2699CrossRefPubMedGoogle Scholar
  25. 25.
    Sharma MS, Webber SA, Morell VO, Gandhi SK, Wearden PD, Buchanan JR, Kormos RL (2006) Ventricular assist device support in children and adolescents as a bridge to heart transplantation. Ann Thorac Surg 82:926–932CrossRefPubMedGoogle Scholar
  26. 26.
    Skouri HN, Dec GW, Friedrich MG, Cooper LT (2006) Noninvasive imaging in myocarditis. J Am Coll Cardiol 48:2085–2093CrossRefPubMedGoogle Scholar
  27. 27.
    Smith NM, Bourne AJ, Clapton WK, Byard RW (1992) The spectrum of presentation at autopsy of myocarditis in infancy and childhood. Pathology 24:129–131CrossRefPubMedGoogle Scholar
  28. 28.
    Taliercio CP, Seward JB, Driscoll DJ, Fisher LD, Gersh BJ, Tajik AJ (1985) Idiopathic dilated cardiomyopathy in the young: clinical profile and natural history. J Am Coll Cardiol 6:1126–1131PubMedCrossRefGoogle Scholar
  29. 29.
    Topkara VK, Dang NC, Barili F, Martens TP, George I, Cheema FH, Bardakci H, Ozcan AV, Naka Y (2006) Ventricular assist device use for the treatment of acute viral myocarditis. J Thorac Cardiovasc Surg 131:1190–1191CrossRefPubMedGoogle Scholar
  30. 30.
    Towbin JA, Lowe AM, Colan SD, Sleeper LA, Orav EJ, Clunie S, Messere J, Cox GF, Lurie PR, Hsu D, Canter C, Wilkinson JD, Lipshultz SE (2006) Incidence, causes, and outcomes of dilated cardiomyopathy in children. JAMA 296:1867–1876CrossRefPubMedGoogle Scholar
  31. 31.
    Wu ET, Huang SC, Chen YS, Wang JK, Wu MH, Ko WJ (2006) Children with fulminant myocarditis rescued with extracorporeal membrane oxygenation. Heart 92:1325–1326CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Darren Klugman
    • 1
    • 6
  • John T. Berger
    • 1
  • Craig A. Sable
    • 2
  • Jianping He
    • 3
  • Sachin G. Khandelwal
    • 4
  • Anthony D. Slonim
    • 5
  1. 1.Critical Care Medicine and Cardiology, Children’s National Medical Center, and Department of PediatricsThe George Washington University School of MedicineWashingtonUSA
  2. 2.Department of Cardiology, Children’s National Medical Center, and Department of PediatricsThe George Washington University School of MedicineWashingtonUSA
  3. 3.Center for Clinical & Community ResearchChildren’s National Medical CenterWashingtonUSA
  4. 4.Center for Clinical EffectivenessChildren’s National Medical CenterWashingtonUSA
  5. 5.Carilion Medical Center and Virginia Tech-Carilion School of MedicineRoanokeUSA
  6. 6.WashingtonUSA

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