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Impact of ventricular arrhythmias on outcomes in children with myocarditis


Children affected with acute myocarditis may progress rapidly into profound ventricular dysfunction and ventricular arrhythmias. The objective of this study is to assess the impact of ventricular arrhythmias on in-hospital mortality and the use of mechanical circulatory support in patients with myocarditis. Pediatric patients (age 0–18 years) admitted with myocarditis were identified from the National Inpatient Sample dataset for the years 2002–2015. A total of 12,489 patients with myocarditis were identified. Of them, 1627 patients were with ventricular arrhythmias and 10,862 patients without ventricular arrhythmias. Mortality was higher in those with ventricular arrhythmias (19.5% vs. 2.8%, OR = 8.47; 95% CI 7.16–10.04; p < 0.001). The median length of stay and the median cost of hospitalization were higher in the ventricular arrhythmias group (9 days vs. 4 days, p < 0.001 and $121,826 vs. $37,658, p < 0.001, respectively). There was a substantial increase in the utilization of extracorporeal membrane oxygenation (ECMO) in patients with ventricular arrhythmias (25.4% vs. 2.7%, OR = 12.40; 95% CI 10.55–14.57; p < 0.001). The use of ventricular assist devices (VADs) was higher in patients with ventricular arrhythmias (4.5% vs. 1.3%, OR = 3.76; 95% CI 2.82–5.01; p < 0.001). An improvement in discharge survival was observed over the years of study in both VA and non-VA groups; associated with this decline in mortality, there was a rising trend of ECMO utilization.

Conclusion: Development of ventricular arrhythmia in children with myocarditis is a strong predictor for mortality and ECMO utilization.

What is Known:

• The clinical presentation of pediatric myocarditis varies from no symptoms of myocardial dysfunction to a rapidly progressing severe congestive heart failure.

• Little is known about the predictors of mortality in children with suspected myocarditis.

What is New:

• Development of ventricular arrhythmia in children with myocarditis is a strong predictor for mortality and ECMO utilization.

• Improvement in discharge survival was observed over the years of study; associated with this decline in mortality, there was a rising trend of ECMO utilization.

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Extracorporeal membrane oxygenation


National inpatient sample


Healthcare Cost and Utilization Project


Agency for Healthcare Research and Quality


International Classification of Disease, Ninth Revision, Clinical Modification


Length of stay


Odds ratio


Confidence interval


  1. Feldman AM, McNamara D (2000) Myocarditis. N Engl J Med 343:1388–1398.

    Article  CAS  PubMed  Google Scholar 

  2. Abe T, Tsuda E, Miyazaki A, Ishibashi-Ueda H, Yamada O (2013) Clinical characteristics and long-term outcome of acute myocarditis in children. Heart Vessel 28:632–638.

    Article  Google Scholar 

  3. Saji T, Matsuura H, Hasegawa K, Nishikawa T, Yamamoto E, Ohki H, Yasukochi S, Arakaki Y, Joo K, Nakazawa M (2012) Comparison of the clinical presentation, treatment, and outcome of fulminant and acute myocarditis in children. Circ J 76:1222–1228.

    Article  PubMed  Google Scholar 

  4. Li L, Zhang Y, Burke A, Xue A, Zhao Z, Fowler D, Shen Y, Li L (2017) Demographic, clinical and pathological features of sudden deaths due to myocarditis: results from a state-wide population-based autopsy study. Forensic Sci Int 272:81–86.

    Article  PubMed  Google Scholar 

  5. Drory Y, Turetz Y, Hiss Y, Lev B, Fisman EZ, Pines A, Kramer MR (1991) Sudden unexpected death in persons <40 years of age. Am J Cardiol 68:1388–1392.

    Article  CAS  PubMed  Google Scholar 

  6. Doolan A, Langlois N, Semsarian C (2004) Causes of sudden cardiac death in young Australians. Med J Aust 180:110–112.

    Article  PubMed  Google Scholar 

  7. Lee KJ, McCrindle BW, Bohn DJ et al (1999) Clinical outcomes of acute myocarditis in childhood. Heart 82:226–233.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Miyake CY, Teele SA, Chen L, Motonaga KS, Dubin AM, Balasubramanian S, Balise RR, Rosenthal DN, Alexander ME, Walsh EP, Mah DY (2014) In-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. Am J Cardiol 113:535–540.

    Article  PubMed  Google Scholar 

  9. Saito J, Niwano S, Niwano H, Inomata T, Yumoto Y, Ikeda K, Inuo K, Kojima J, Horie M, Izumi T (2002) Electrical remodeling of the ventricular myocardium in myocarditis: studies of rat experimental autoimmune myocarditis. Circ J 66:97–103.

    Article  PubMed  Google Scholar 

  10. Sharma JR, Sathanandam S, Rao SP, Acharya S, Flood V (2008) Ventricular tachycardia in acute fulminant myocarditis: medical management and follow-up. Pediatr Cardiol 29:416–419.

    Article  CAS  PubMed  Google Scholar 

  11. Teele SA, Allan CK, Laussen PC, Newburger JW, Gauvreau K, Thiagarajan RR (2011) Management and outcomes in pediatric patients presenting with acute fulminant myocarditis. J Pediatr 158:158–643.e1.

    Article  Google Scholar 

  12. Klugman D, Berger JT, Sable CA, He J, Khandelwal SG, Slonim AD (2010) Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol 31:222–228.

    Article  PubMed  Google Scholar 

  13. Barfuss SB, Butts R, Knecht KR, Prada-Ruiz A, Lal AK (2019) Outcomes of myocarditis in patients with normal left ventricular systolic function on admission. Pediatr Cardiol 40:1171–1174.

    Article  PubMed  Google Scholar 

  14. Chang YJ, Hsiao HJ, Hsia SH et al (2019) Analysis of clinical parameters and echocardiography as predictors of fatal pediatric myocarditis. PLoS One 14:1–11

    Google Scholar 

  15. Kühn B, Shapiro ED, Walls TA, Friedman AH (2004) Predictors of outcome of myocarditis. Pediatr Cardiol 25:379–384.

    Article  PubMed  Google Scholar 

  16. Barbaro RP, Paden ML, Guner YS, Raman L, Ryerson LM, Alexander P, Nasr VG, Bembea MM, Rycus PT, Thiagarajan RR, ELSO member centers (2017) Pediatric Extracorporeal Life Support Organization Registry international report 2016. ASAIO J 63:456–463.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Mahmood B, Newton D, Pallotto EK (2018) Current trends in neonatal ECMO. Semin Perinatol 42:80–88.

    Article  PubMed  Google Scholar 

  18. Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D, Thiagarajan RR (2010) Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the Extracorporeal Life Support Organization registry. Crit Care Med 38:382–387.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Reiss N, El-Banayosy A, Arusoglu L et al (2006) Acute fulminant myocarditis in children and adolescents: the role of mechanical circulatory assist. ASAIO J 52:211–214.

    Article  PubMed  Google Scholar 

  20. Jefferies JL, Morales DL (2012) Mechanical circulatory support in children: bridge to transplant versus recovery. Curr Heart Fail Rep 9:236–243.

    Article  PubMed  Google Scholar 

  21. Li Y, Yu Y, Chen S, Liao Y, Du J (2019) Corticosteroids and intravenous immunoglobulin in pediatric myocarditis: a meta-analysis. Front Pediatr 7:342.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations



Dr. Othman carried out the initial analyses, drafted, reviewed, and revised the manuscript.

Dr. Byrnes drafted, reviewed, and revised the manuscript.

Dr. Elsamny drafted, reviewed, and revised the manuscript.

Dr. Hamzah conceptualized and designed the study, drafted, and critically reviewed the manuscript for important intellectual content.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Mohammed Hamzah.

Ethics declarations

The study was granted an exempt status from the Cleveland Clinic Institutional Review Board (May 16, 2019).

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

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Communicated by Piet Leroy

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Othman, H.F., Byrnes, J., Elsamny, E. et al. Impact of ventricular arrhythmias on outcomes in children with myocarditis. Eur J Pediatr 179, 1779–1786 (2020).

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  • Myocarditis
  • Ventricular arrhythmia
  • Mortality
  • ECMO
  • Heart transplant