Acute viral myocarditis

Definition ,causes ,pathophysiology ,presentations ,diagnosis,differential diagnosis,Management ,prognosis,

1. Acute Viral Myocarditis Prof. Dr. Saad S al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital ,Sharjah ,UAE [email protected]

2. Myocarditis Myocarditis is an inflammatory disease of the cardiac muscle caused by myocardial infiltration of immunocompetent cells following any kind of cardiac injury 2/3/2015 Acute myocarditis Prof. Dr. Saad S Al Ani Khorfakkan Hospital 2 http://eurheartj.oxfordjournals.org

3. Acute myocarditis Is often a result of a viral infection that produces myocardial necrosis and triggers an immune response to eliminate the infectious agent 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 3

4. Causes 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 4 Viral Infections are the most common etiology though myocardial toxins , drug exposures , hypersensitivity reactions ,and immune disorders

5. Causes (cont.) Coxsackievirus and other enteroviruses, adenovirus , parvovirus , Epstein-Barr virus , and cytomegalovirus are the most common causative agents in children 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 5

6. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 6 Coxsackie A + B Echovirus Poliovirus Hepatitis virus Influenza Respiratory Syncitial virus M umps Rubella Dengue Fever Yellow Fever

7. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 7 A 1, 2 ,3, and 5 1 (B19V) and 2 Human herpes virus 6 A/B Cytomegalovirus HIV Epstein-Barr virus Varicella-zoster virus

8. Epidemiology Manifestations are age dependent : In infants viral myocarditis can be fulminant In children acute, myopericarditis with congestive heart failure In older children and adolescents acute or chronic congestive heart failure . 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 8

9. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 9 http://eurheartj.oxfordjournals.org

10. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 10 http://eurheartj.oxfordjournals.org

11. Clinical Manifestations 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 11

12. Children with myocarditis present with symptoms that can be mistaken for other types of illnesses; respiratory presentations were most common. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 12

13. Clinical Manifestations (cont.) 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 13

14. Clinical Manifestations (cont.) 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 14

15. Clinical Manifestations (cont.) 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 15

16. Clinical Manifestations (cont.) 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 16

17. Diagnosis Electrocardiographic changes Are nonspecific May include: Sinus tachycardia Atrial or ventricular arrhythmias Heart block Diminished QRS voltages Nonspecific ST and T-wave changes often suggestive of acute ischemia. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 17

18. Diagnosis (cont.) Chest roentgenograms In severe , symptomatic cases reveal: Cardiomegaly Pulmonary vascular prominence Overt pulmonary edema Pleural effusions . 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 18

19. Diagnosis (cont.) Echocardiography Often shows: Diminished ventricular systolic function Cardiac chamber enlargement Mitral insufficiency Pericardial infusion (occasionally) 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 19

20. Diagnosis (cont.) Endomyocardial biopsy May be useful in identifying inflammatory cell infiltrates or myocyte damage M olecular viral analysis using polymerase chain reaction (PCR ) techniques. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 20

21. Diagnosis (cont.) Catheterization and biopsy Should be performed in: Patients suspected to have myocarditis If there is strong suspicion for unusual forms of cardiomyopathy such as storage diseases or mitochondrial defects 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 21

22. Diagnosis (cont.) Supportive but nonspecific tests include Sedimentation rate CPK isoenzymes Cardiac troponin I Brain natriuretic peptide (BNP) levels 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 22

23. Differential diagnosis * Carnitine deficiency * Other metabolic disorders of energy generation *Hereditary mitochondrial defects * Idiopathic dilated cardiomyopathy *Pericarditis * Anomalies of the coronary arteries 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 23

24. Management Primary therapy for acute myocarditis is supportive Acutely , the use of inotropic agents , preferably milrinone , should be entertained but used with caution because of their pro-arrhythmic potential. Diuretics are often required as well . 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 24

25. Management (cont.) In extremis , mechanical ventilatory support and mechanical circulatory support with : * Ventricular assist device implantation or *ECMO May be needed to: *Stabilize the patient’s hemodynamic status *Act as a bridge to recovery or cardiac transplantation. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 25

26. Management (cont.) In patients with compensated congestive heart failure in the outpatient setting : * Diuretics * Angiotensin-converting enzyme inhibitors * Angiotensin receptor blockers are of use but may be contraindicated in those presenting with fulminant heart failure and cardiovascular collapse . 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 26

27. Management (cont.) Significant atrial or ventricular arrhythmias: Specific antiarrhythmic agents ( amiodarone ) should be administered and ICD placement considered . Immunomodulation is controversial. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 27

28. Management (cont.) Intravenous immune globulin may have a role in the treatment of acute or fulminant myocarditis Corticosteroids ? 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 28

29. Management (cont.) Relapse has been noted in patients receiving immunosuppression Specific antiviral therapies ? 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 29

30. Prognosis In newborns with symptomatic acute myocarditis is poor , and 75% mortality In children and adolescents is better Persistent evidence of dilated cardiomyopathy → need for cardiac transplantation . Recovery of ventricular function has been reported in 10-50% of patients 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 30

31. References Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J . Sep 2008;29(17):2073-82. Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs . 2002;4(3):171-81 Renko M, Leskinen M, Kontiokari T, et al. Cardiac troponin-I as a screening tool for myocarditis in children hospitalized for viral infection. Acta Paediatr . Nov 4 2009 Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation . Pediatrics . Dec 2007;120(6):1278-85 . 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 31

32. 2/3/2015 Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 32