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Myokarditis in der Differenzialdiagnose von Kardiomyopathien

Endomyokardiale Biopsie oder MRT?

Myocarditis in the differential diagnosis of cardiomyopathies

Endomyocardial biopsy or MRI?

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Zusammenfassung

Die Myokarditis ist eine entzündliche Erkrankung des Herzmuskels, die zumeist durch eine virale Infektion ausgelöst wird und bei chronischem Verlauf in eine dilatative Kardiomyopathie übergehen kann. Die Diagnose einer Myokarditis stellt angesichts der variablen klinischen Symptomatik und des Mangels an hinreichend sensitiven diagnostischen Tests eine große Herausforderung im klinischen Alltag dar. Dabei hat sich in den vergangenen Jahren die kardiale Magnetresonanztomographie (MRT) als zusätzliches diagnostisches Verfahren etabliert. Durch Analyse von „edema ratio“, „early gadolinium enhancement ratio“ und „late gadolinium enhancement“ können hier neben Struktur- und Funktionsanalysen auch Aussagen über bestimmte myokardiale Gewebecharakteristika gemacht werden. Die Anwendung dieser Parameter in größeren und besser charakterisierten Patientenkollektiven sowie die technische Validierung neuer Verfahren, wie z. B. des T1- oder T2-Mapping, sind jedoch erforderlich, um den diagnostischen und prognostischen Nutzen der kardialen MRT zu optimieren. Die definitive Diagnosestellung einer Myokarditis erfordert weiterhin die immunhistologische Analyse von Myokardgewebe aus der Endomyokardbiopsie, welche als einziges Verfahren auch Anhaltspunkte für die Ätiologie der Erkrankung bietet. Die myokardbioptischen Analysen bilden die Grundlage für spezifische Therapieentscheidungen, besitzen aber nur eingeschränkt prognostische Relevanz. Zukünftig bedarf es Weiterentwicklungen im Bereich der MR-Bildgebung sowie in der Laboranalyse von Myokardbiopsien und Serummarkern, um die Diagnostik der Myokarditis zu vereinfachen und neue therapeutische Ansatzpunkte zu entwickeln.

Abstract

Myocarditis is an inflammatory disease of the heart muscle commonly caused by viral pathogens. Dilated cardiomyopathy is a major long-term sequela of myocarditis and at least in part related to post-viral immune-mediated responses. Establishing a diagnosis of myocarditis represents a major challenge because of the variable clinical picture and the lack of readily available, non-invasive diagnostic tests. In recent years, cardiac magnetic resonance imaging (cMRI) has emerged as a promising additional diagnostic tool in patients with suspected myocarditis: cMRI not only provides important insights into structural and functional abnormalities of the heart but relevant tissue pathologies can also be visualized. The diagnostic accuracy of three tissue criteria, i.e. the edema ratio, early gadolinium enhancement ratio and late gadolinium enhancement, has been characterized in several studies. Endomyocardial biopsy (EMB) is widely considered to be the reference standard for diagnosis of myocarditis. Although limited by sampling error, EMB is the only diagnostic procedure that can be used to confirm myocarditis. Laboratory analyses of EMB may provide information about specific causes of myocarditis and are, at least in part, of prognostic relevance. In a subset of patients the results of EMB may guide therapeutic decision-making. Additional efforts are needed in cardiac imaging, molecular characterization of EMB and evaluation of serum biomarkers to improve the diagnostic work-up in patients with suspected myocarditis and to identify potential novel targets for a cause-specific therapy of myocarditis.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Besler, G. Schuler und P. Lurz geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Abteilung Innere Medizin/Kardiologie, Universität Leipzig – Herzzentrum, Strümpellstr. 39, 04289, Leipzig, Deutschland

    C. Besler, G. Schuler &  P. Lurz

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  1. C. Besler
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  2. G. Schuler
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  3. P. Lurz
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Correspondence to P. Lurz.

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Besler, C., Schuler, G. & Lurz, P. Myokarditis in der Differenzialdiagnose von Kardiomyopathien. Herz 40, 607–615 (2015). https://doi.org/10.1007/s00059-015-4229-z

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