Skip to main content
SpringerLink
Log in

Combination of echocardiography and emergency endomyocardial biopsy for suspected myocarditis in the cardiovascular emergency medical care

  • Review Article
  • Published:
Journal of Echocardiography Aims and scope Submit manuscript

Abstract

Myocarditis is a fatal inflammatory disease of myocardium, diagnosed with clinical and histopathological findings by endomyocardial biopsy (EMB). Myocarditis has a variety of clinical presentations and a dynamic and sometimes rapid process of severity. Echocardiography plays an important role in the management of myocarditis because it has noninvasiveness and portability. Once acute myocarditis is suspected by an echocardiography, pathological information should be required as early as possible. In our cardiovascular center, emergency EMB suspecting myocarditis was performed in 19 cases (1.3%) among consecutive 1469 cases (70.1 ± 12.6 years old, male 67.5%) undergoing emergency coronary angiograms from April 2014 to September 2017. Hematoxylin–eosin stain of the biopsy specimens were prepared with microwave-accelerated histoprocessing within 3–5 hours after EMB for rapid pathological diagnosis of myocarditis. We reviewed the value of emergency echo-EMB combination leading to the early decision making of intensive care, corticosteroids and proper mechanical circulatory support prior to the possible sudden collapse in patients with myocarditis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Cooper LT Jr. Myocarditis. N Engl J Med. 2009;360:1526–38.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. Lancet. 2012;379:738–47.

    Article  PubMed  Google Scholar 

  3. Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34:2636–48 (48a-48d).

    Article  PubMed  Google Scholar 

  4. Pahuja M, Adegbala O, Mishra T, et al. Trends in the incidence of in-hospital mortality, cardiogenic shock, and utilization of mechanical circulatory support devices in myocarditis (analysis of national inpatient sample data, 2005–2014). J Card Fail. 2019;25:457–67.

    Article  PubMed  Google Scholar 

  5. Ammirati E, Veronese G, Cipriani M, et al. Acute and fulminant myocarditis: a pragmatic clinical approach to diagnosis and treatment. Curr Cardiol Rep. 2018;20:114.

    Article  PubMed  Google Scholar 

  6. Ammirati E, Cipriani M, Moro C, et al. Clinical presentation and outcome in a contemporary cohort of patients with acute myocarditis. Circulation. 2018;138:1088–99.

    Article  PubMed  Google Scholar 

  7. Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations. J Am Coll Cardiol. 2018;72:3158–76.

    Article  PubMed  Google Scholar 

  8. Bozkurt B, Colvin M, Cook J, et al. Current diagnostic and treatment strategies for specific dilated cardiomyopathies: a scientific statement from the American heart association. Circulation. 2016;134:e579–646.

    Article  PubMed  Google Scholar 

  9. Ammirati E, Veronese G, Bottiroli M, et al. Update on acute myocarditis. Trends Cardiovasc Med. 2020.

  10. Kociol RD, Cooper LT, Fang JC, et al. Recognition and Initial management of fulminant myocarditis: a scientific statement from the American heart association. Circulation. 2020;141:e69–92.

    Article  PubMed  Google Scholar 

  11. Pinamonti B, Alberti E, Cigalotto A, et al. Echocardiographic findings in myocarditis. Am J Cardiol. 1988;62:285–91.

    Article  CAS  PubMed  Google Scholar 

  12. Skouri HN, Dec GW, Friedrich MG, et al. Noninvasive imaging in myocarditis. J Am Coll Cardiol. 2006;48:2085–93.

    Article  PubMed  Google Scholar 

  13. Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis. 2010;52:274–88.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Leone O, Veinot JP, Angelini A, et al. 2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovasc Pathol. 2012;21:245–74.

    Article  PubMed  Google Scholar 

  15. 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;116:2216–33.

    Article  PubMed  Google Scholar 

  16. Assomull RG, Lyne JC, Keenan N, et al. The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries. Eur Heart J. 2007;28:1242–9.

    Article  CAS  PubMed  Google Scholar 

  17. Ammirati E, Moroni F, Sormani P, et al. Quantitative changes in late gadolinium enhancement at cardiac magnetic resonance in the early phase of acute myocarditis. Int J Cardiol. 2017;231:216–21.

    Article  PubMed  Google Scholar 

  18. Lagan J, Schmitt M, Miller CA. Clinical applications of multi-parametric CMR in myocarditis and systemic inflammatory diseases. Int J Cardiovasc Imaging. 2018;34(1):35–54.

    Article  PubMed  Google Scholar 

  19. Francone M, Chimenti C, Galea N, et al. CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis. JACC Cardiovasc Imaging. 2014;7:254–63.

    Article  PubMed  Google Scholar 

  20. Veronese G, Ammirati E, Cipriani M, et al. Fulminant myocarditis: characteristics, treatment, and outcomes. Anatol J Cardiol. 2018;19:279–86.

    PubMed  PubMed Central  Google Scholar 

  21. Smith SC, Ladenson JH, Mason JW, et al. Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates. Circulation. 1997;95:163–8.

    Article  CAS  PubMed  Google Scholar 

  22. Gilotra NA, Minkove N, Bennett MK, et al. Lack of relationship between serum cardiac troponin I level and giant cell myocarditis diagnosis and outcomes. J Card Fail. 2016;22:583–5.

    Article  CAS  PubMed  Google Scholar 

  23. Mason JW, O’Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995;333:269–75.

    Article  CAS  PubMed  Google Scholar 

  24. Jani SM, Nallamothu BK, Cooper LT, et al. Beating, fast and slow. N Engl J Med. 2017;377:72–8.

    Article  PubMed  Google Scholar 

  25. Ammirati E, Cipriani M, Lilliu M, et al. Survival and left ventricular function changes in fulminant versus nonfulminant acute myocarditis. Circulation. 2017;136:529–45.

    Article  PubMed  Google Scholar 

  26. Aoyama N, Izumi T, Hiramori K, et al. National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee). Circ J. 2002;66:133–44.

    Article  PubMed  Google Scholar 

  27. Hsu KH, Chi NH, Yu HY, et al. Extracorporeal membranous oxygenation support for acute fulminant myocarditis: analysis of a single center’s experience. Eur J Cardiothorac Surg. 2011;40:682–8.

    PubMed  Google Scholar 

  28. Diddle JW, Almodovar MC, Rajagopal SK, et al. Extracorporeal membrane oxygenation for the support of adults with acute myocarditis. Crit Care Med. 2015;43:1016–25.

    Article  CAS  PubMed  Google Scholar 

  29. Lorusso R, Centofanti P, Gelsomino S, et al. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Ann Thorac Surg. 2016;101:919–26.

    Article  PubMed  Google Scholar 

  30. Reyentovich A, Barghash MH, Hochman JS. Management of refractory cardiogenic shock. Nat Rev Cardiol. 2016;13:481–92.

    Article  PubMed  Google Scholar 

  31. Schubert S, Opgen-Rhein B, Boehne M, et al. Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: results from the prospective multicenter registry “MYKKE.” Pediatr Transplant. 2019;23:e13548.

    Article  PubMed  Google Scholar 

  32. Meani P, Gelsomino S, Natour E, et al. Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature. Eur J Heart Fail. 2017;19:84–91.

    Article  PubMed  Google Scholar 

  33. Luyt CE, Hékimian G, Ginsberg F. What’s new in myocarditis? Intensive Care Med. 2016;42:1055–7.

    Article  PubMed  Google Scholar 

  34. Heymans S, Eriksson U, Lehtonen J, et al. The quest for new approaches in myocarditis and inflammatory cardiomyopathy. J Am Coll Cardiol. 2016;68:2348–64.

    Article  PubMed  Google Scholar 

  35. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–200.

    Article  PubMed  Google Scholar 

  36. Brambatti M, Matassini MV, Adler ED, et al. Eosinophilic myocarditis: characteristics, treatment, and outcomes. J Am Coll Cardiol. 2017;70:2363–75.

    Article  PubMed  Google Scholar 

  37. Ammirati E, Stucchi M, Brambatti M, et al. Eosinophilic myocarditis: a paraneoplastic event. Lancet. 2015;385:2546.

    Article  PubMed  Google Scholar 

  38. Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, et al. Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. Circulation. 2001;104:39–45.

    Article  CAS  PubMed  Google Scholar 

  39. Frustaci A, Russo MA, Chimenti C. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. Eur Heart J. 2009;30:1995–2002.

    Article  CAS  PubMed  Google Scholar 

  40. Postow MA, Callahan MK, Wolchok JD. immune checkpoint blockade in cancer therapy. J Clin Oncol. 2015;33:1974–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Johnson DB, Balko JM, Compton ML, et al. Fulminant myocarditis with combination immune checkpoint blockade. N Engl J Med. 2016;375:1749–55.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Moslehi JJ, Salem JE, Sosman JA, et al. Increased reporting of fatal immune checkpoint inhibitor-associated myocarditis. Lancet. 2018;391:933.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Mahmood SS, Fradley MG, Cohen JV, et al. Myocarditis in patients treated with immune checkpoint inhibitors. J Am Coll Cardiol. 2018;71:1755–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Palaskas N, Lopez-Mattei J, Durand JB, et al. Immune checkpoint inhibitor myocarditis: pathophysiological characteristics, diagnosis, and treatment. J Am Heart Assoc. 2020;9:e013757.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Brahmer JR, Lacchetti C, Schneider BJ, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American society of clinical oncology clinical practice guideline. J Clin Oncol. 2018;36:1714–68.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, 738-1 Funado, Shinbeppu-cho, Miyazaki, 880-0834, Japan

    Hirohide Matsuura, Nozomi Watanabe & Yoshisato Shibata

  2. Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

    Yujiro Asada

Authors
  1. Hirohide Matsuura
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nozomi Watanabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yoshisato Shibata
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yujiro Asada
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hirohide Matsuura.

Ethics declarations

Conflict of interest

Hirohide Matsuura, Nozomi Watanabe, Yoshisato Shibata, and Yujiro Asada declare that they have no conflict of interest. The authors have no relationships relevant to the contents of this paper to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (MPG 1121 KB)

Supplementary file2 (MPG 837 KB)

Supplementary file3 (MPG 839 KB)

Supplementary file4 (AVI 6393 KB)

Supplementary file5 (AVI 6035 KB)

Supplementary file6 (AVI 4696 KB)

Supplementary file7 (MPG 1067 KB)

Supplementary file8 (MPG 1049 KB)

Supplementary file9 (MPG 757 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Matsuura, H., Watanabe, N., Shibata, Y. et al. Combination of echocardiography and emergency endomyocardial biopsy for suspected myocarditis in the cardiovascular emergency medical care. J Echocardiogr 19, 86–94 (2021). https://doi.org/10.1007/s12574-021-00521-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12574-021-00521-0

Keywords

Search

Navigation