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Acute myocarditis in children: Current concepts and management

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Opinion statement

The spectrum of presentation of pediatric myocarditis ranges from minor flu-like illness with chest pain to acute cardiogenic shock in a previously healthy child. A major change in the diagnostic evaluation of myocarditis is a shift in focus away from endomyocardial biopsy and histologic confirmation toward cardiac MRI for noninvasive diagnosis and prognostication of acute myocarditis. Cardiac MRI may be particularly useful in pediatric patients, considering the risks associated with biopsy in children. Some of the MRI characteristics seen in pediatric patients with acute myocarditis also may serve as predictors of outcome. The approach to managing myocarditis varies according to the severity of presentation; it is primarily supportive while spontaneous recovery of cardiac function is awaited. For subacute heart failure, the mainstay of therapy is still supportive management with oral heart failure medications such as angiotensin-converting enzyme inhibitors, β-blockers, and diuretics. Acute myocarditis presenting with severe symptomatology, termed fulminant myocarditis, has a high recovery rate. Aggressive supportive care, including mechanical circulatory support, is indicated in fulminant myocarditis. With the increasing availability of and experience with paracorporeal pulsatile mechanical assist devices for children, more and more young patients are being bridged to transplantation or recovery. Despite promising results from several uncontrolled pediatric studies using immunosuppressive and/or immunomodulating therapy with intravenous γ-globulin, the translation of these results into a recommended, routine therapy for pediatric myocarditis has been complicated by the high rate of spontaneous improvement of myocarditis with supportive care and the lack of demonstrable benefit for such therapies in blinded, randomized, placebo-controlled trials in adult myocarditis. Further clinical studies are necessary to define the possible utility of immunosuppressive, immunomodulatory, and antiviral therapy. Heart transplantation remains the final therapeutic option for children with myocarditis and intractable severe heart failure.

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References and Recommended Reading

  1. Aretz HT, Billingham ME, Edwards WD, et al.: Myocarditis: a histopathologic definition and classification. Am J Cardiovasc Pathol 1987, 1:3–14.

    PubMed  CAS  Google Scholar 

  2. Bowles NE, Bowles KR, Towbin JA: Viral genome detection and outcome in myocarditis. Heart Failure Clin 2005, 1:407–417.

    Article  Google Scholar 

  3. Kühl U, Pauschinger M, Noutsias M, et al.: High prevalence of viral genomes and multiple viral infections in the myocardium of adults with “idiopathic” left ventricular dysfunction. Circulation 2005, 111:887–893.

    Article  PubMed  Google Scholar 

  4. Cooper LT: Myocarditis. N Engl J Med 2009, 360:1526–1538.

    Article  PubMed  CAS  Google Scholar 

  5. Bowles NE, Ni J, Kearney DL, et al.: Detection of viruses in myocardial tissues by polymerase chain reaction. Evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol 2003, 42:466–472.

    Article  PubMed  Google Scholar 

  6. Maron BJ, Doerer JJ, Haas TS, et al.: Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation 2009, 119:1085–1092.

    Article  PubMed  Google Scholar 

  7. Nugent AW, Daubeney PEF, Chondros P, et al.: The epidemiology of childhood cardiomyopathy in Australia. N Engl J Med 2003, 348:1639–1646.

    Article  PubMed  Google Scholar 

  8. Towbin JA, Lowe AM, Colan SD, et al.: Incidence, causes, and outcomes of dilated cardiomyopathy in children. JAMA 2006, 296:1867–1876.

    Article  PubMed  CAS  Google Scholar 

  9. Friedrich MG, Sechtem U, Schulz-Menger J, et al.: Cardiovascular magnetic resonance in myocarditis: a JACC white paper. J Am Coll Card 2009, 53:1475–1487.

    Article  Google Scholar 

  10. Liu PP, Yan AT: Cardiovascular magnetic resonance for the diagnosis of acute myocarditis. Prospects for detecting myocardial inflammation. J Am Coll Cardiol 2005, 45:1823–1825.

    Article  PubMed  Google Scholar 

  11. Grogan M, Redfield MM, Bailey KR, et al.: Long-term outcome of patients with biopsy-proven myocarditis: comparison with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1995, 26:80–84.

    Article  PubMed  CAS  Google Scholar 

  12. Cooper LT, Baughman KL, Feldman AM, et al.: The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, The American College of Cardiology, and the European Society of Cardiology. Circulation 2007, 116:2216–2233.

    Article  PubMed  Google Scholar 

  13. Foerester S, Canter C, Carey A, et al.: A comparative analysis of outcomes for pediatric patients with biopsy-proven myocarditis, clinically-diagnosed myocarditis and idiopathic dilated cardiomyopathy. Circulation 2007, 116:II–565.

    Google Scholar 

  14. Laissy JP, Hyafil F, Feldman LJ, et al.: Differentiating acute myocardial infarction from myocarditis: diagnostic value of early- and delayed-perfusion cardiac MR imaging. Radiology 2005, 237:75–82.

    Article  PubMed  Google Scholar 

  15. Vashist S, Woodard PK, Singh G, et al.: MRI characteristics of acute myocarditis in pediatric patients: patterns and predictors of outcomes. J Am Coll Cardiol 2009, 53:A144–A197.

    Article  Google Scholar 

  16. Rosenthal D, Chrisant MR, Edens E, et al.: International Society for Heart and Lung Transplantation: practice guidelines for management of heart failure in children. J Heart Lung Transplant 2004, 23:1313–1333.

    Article  PubMed  Google Scholar 

  17. Rosenzweig EB, Starc TJ, Chen JM, et al.: Intravenous arginine-vasopressin in children with vasodilatory shock after cardiac surgery. Circulation 1999, 100:II182–II186.

    PubMed  CAS  Google Scholar 

  18. Feingold B, Law YM: Nesiritide use in pediatric patients with congestive heart failure. J Heart Lung Transplant 2004, 23:1455–1459.

    Article  PubMed  Google Scholar 

  19. Emanuele C, Roberto P, Filippo M, et al.: Mechanical circulatory support for patients with fulminant myocarditis: the role of echocardiography to address diagnosis, choice of device, management, and recovery. J Cardiothorac Vasc Anesth 2009, 23:87–94.

    Article  Google Scholar 

  20. Duncan BW: Mechanical circulatory support for infants and children with cardiac disease. Ann Thorac Surg 2002, 73:1670–1677.

    Article  PubMed  Google Scholar 

  21. Fiser WP, Yetman AT, Gunselman RJ, et al.: Pediatric arteriovenous extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation. J Heart Lung Transplant 2003, 22:770–777.

    Article  PubMed  Google Scholar 

  22. Chen YS, Yu HS, Huang SC, et al.: Experience and results of extracorporeal membrane oxygenation in treating fulminant myocarditis with shock: what mechanical support should be considered first? J Heart Lung Transplant 2005, 24:81–87.

    Article  PubMed  Google Scholar 

  23. Reinhartz O, Copeland JG, Farrar DJ: Thoratec ventricular assist devices in children with less than 1.3 m2 body surface area. ASAIO J 2003, 49:727–730.

    Article  PubMed  Google Scholar 

  24. Cooper DS, Jacobs JP, Moore L, et al.: Cardiac extracorporeal life support: state of the art in 2007. Cardiol Young 2007, 17:104–115.

    Article  PubMed  Google Scholar 

  25. Davies RR, Russo MJ, Hong KN, et al.: The use of mechanical circulatory support as a bridge to transplantation in pediatric patients: an analysis of the United Network for Organ Sharing database. J Thorac Cardiovasc Surg 2008, 135:421–427.

    Article  PubMed  Google Scholar 

  26. Gandhi SK, Huddleston CB, Balzer DT, et al.: Biventricular assist devices as a bridge to heart transplantation in small children. Circulation 2008, 118:S89–S93.

    Article  PubMed  Google Scholar 

  27. Matsurnori A, Igata H, Ono K, et al.: High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity. Jpn Circ J 1999, 63:2476–2478.

    Google Scholar 

  28. Adams KF Jr, Gheorghiade M, Uretsky BE, et al.: Clinical benefits of low serum digoxin on the treatment of heart failure. J Am Coll Cardiol 2002, 39:946–953.

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  30. Bruns LA, Chrisant MK, Lamour JM, et al.: Carvedilol as therapy in pediatric heart failure: an initial multicenter experience. J Pediatr 2001, 138:505–511.

    Article  PubMed  CAS  Google Scholar 

  31. Rusconi P, Gomez-Marin O, Rossique-Gonzalez M, et al.: Carvedilol in children with cardiomyopathy: 3 years experience in a single institution. J Heart Lung Transplant 2004, 23:832–838.

    Article  PubMed  Google Scholar 

  32. Frobel AK, Hulpke-Wette M, Schmidt KG, et al.: Betablockers for congestive heart failure in children. Cochrane Database Syst Rev 2009, CD007037.

  33. Shaddy RE, Boucek MM, Canter CE, et al.: Carvedilol for children and adolescents with heart failure: a randomized controlled trial. JAMA 2007, 298:1171–1179.

    Article  PubMed  Google Scholar 

  34. Maisch B, Herzum M, Hufnagel G, et al.: Immunosuppressive treatment for myocarditis and dilated cardiomyopathy. Eur Heart J 1995, 16(Suppl O):153–161.

    PubMed  CAS  Google Scholar 

  35. Gouton M, Difilippo S, Sassolas F, et al.: Acute infectious myocarditis in childhood: results from 2 series from Lyon. Arch Mal Coeur Vaiss 1995, 88:753–759.

    PubMed  CAS  Google Scholar 

  36. Kawai C: From myocarditis to cardiomyopathy: mechanisms of inflammation and cell death. Circulation 1999, 99:1091–1100.

    PubMed  CAS  Google Scholar 

  37. Liu PP, Mason JW: Advances in the understanding of myocarditis. Circulation 2001, 104:1076–1082.

    Article  PubMed  CAS  Google Scholar 

  38. Cooper JT Jr: Giant cell myocarditis: diagnosis and treatment. Herz 2000, 25:291–298.

    Article  PubMed  Google Scholar 

  39. Galiuto L, Enriquez-Sarano M, Reeder GS, et al.: Eosinophilic myocarditis manifesting as myocardial infarction: early diagnosis and successful treatment. Mayo Clin Proc 1997, 72:603–610.

    Article  PubMed  CAS  Google Scholar 

  40. Mason JW, O’Connell JB, Herskowitz A, et al.: A clinical trial of immunosuppressive therapy for myocarditis. N Engl J Med 1995, 333:269–275.

    Article  PubMed  CAS  Google Scholar 

  41. Parillo JE: Inflammatory cardiomyopathy (myocarditis). Which patients should be treated with anti-inflammatory therapy? Circulation 2001, 104:4–6.

    Article  Google Scholar 

  42. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction-pharmacologic approaches. J Card Fail 1999, 5:357–382.

  43. Wojnicz R, Nowalany-Kozielska E, Wojciechowaska C, et al.: Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy. Circulation 2001, 104:39–45.

    Article  PubMed  CAS  Google Scholar 

  44. Frustaci A, Chimenti C, Calabrese F, et al.: Immunosuppressive therapy for active lymphocytic myocarditis. Virological and immunological profile of responders versus nonresponders. Circulation 2003, 107:857–863.

    Article  PubMed  Google Scholar 

  45. Hia CP, Yip WC, Tai BC, Quek SC: Immunosuppressive therapy in acute myocarditis: an 18-year systematic review. Arch Dis Child 2004, 89:580–584.

    Article  PubMed  CAS  Google Scholar 

  46. Gagliardi MG, Bevilacqua M, Bassano C, et al.: Long-term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart 2004, 90:1167–1171.

    Article  PubMed  Google Scholar 

  47. Burch M: Immune suppressive treatment in paediatric myocarditis: still awaiting the evidence. Heart 2004, 90:1103–1104.

    Article  PubMed  CAS  Google Scholar 

  48. Liu C, Chen J, Liu K: Immunosuppressive treatment for inflammatory cardiomyopathy: meta-analysis of randomized controlled trials. Int Heart J 2005, 46:113–122.

    Article  PubMed  CAS  Google Scholar 

  49. Drucker A, Colan SD, Lewis AB, et al.: Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 1994, 89:252–257.

    PubMed  CAS  Google Scholar 

  50. McNamara DM, Rosenblum WD, Janosko KM, et al.: Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation 1997, 95:2476–2478.

    PubMed  CAS  Google Scholar 

  51. McNamara DM, Holubkov R, Starling RC, et al.: Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation 2001, 103:2254–2259.

    PubMed  CAS  Google Scholar 

  52. Robinson J, Hartling L, Vandermeer B, et al.: Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005, CD004370.

  53. Kuhl U, Pauschinger M, Schwimmbeck PL, et al.: Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation 2003, 107:2793–2798.

    Article  PubMed  Google Scholar 

  54. Keren A: Invited for debate: is virus persistence a determinant for disease progression? Ernst Schering Res Found Workshop 2006, 55–61.

  55. Heymans S, Hirsch E, Anker SD, et al.: Inflammation as a therapeutic target in heart failure? A scientific statement from the Translational Research Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009, 11:119–129.

    Article  PubMed  CAS  Google Scholar 

  56. Nugent AW, Davis AM, Kleinert S, et al.: Clinical, electrocardiographic, and histologic correlations in children with dilated cardiomyopathy. J Heart Lung Transplant 2001, 20:1152–1157.

    Article  PubMed  CAS  Google Scholar 

  57. Duncan BW, Bohn EJ, Atz AM, et al.: Mechanical circulatory support for the treatment of children with acute fulminant myocarditis. J Thorac Cardiovasc Surg 2001, 122:440–448.

    Article  PubMed  CAS  Google Scholar 

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

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, 1 Children’s Place, Campus Box 8116-NWT, St. Louis, MO, 63119, USA

    Sudhir Vashist

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  1. Sudhir Vashist
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  2. Gautam K. Singh
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Correspondence to Sudhir Vashist.

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Vashist, S., Singh, G.K. Acute myocarditis in children: Current concepts and management. Curr Treat Options Cardio Med 11, 383–391 (2009). https://doi.org/10.1007/s11936-009-0039-z

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