2017


To access this material please log in or register

Register Authorize
2017/№S3

Interventional treatment in patients with myocarditis: Pro and Contra

Syrovnev V. A., Lebedev D. S., Mitrofanova L. B., Lebedeva V. K., Tatarsky R. B., Mikhaylov E. N., Moiseeva O. M.
Federal Almazov North-West Medical Research Cente, Akkuratova 2, St. Petersburg 197341

Keywords: ventricular rhythm disorder, sudden cardiac death, dilated cardiomyopathy, endomyocardial biopsy, implantable cardioverter-defibrillator, radiofrequency ablation

DOI: 10.18087/cardio.2405

Aim. Ventricular tachyarrhythmias (VTs) are often encountered in patients with inflammatory heart diseases. VT can become lifethreatening in patients with myocarditis, and the management may vary in different types of myocarditis. Purpose of the study is to describe VT characteristics in patients with verified myocarditis, and to evaluate the efficacy and safety of VT management, when tailored to the type of myocarditis. Materials and methods. Study population comprised: 56 patients with morphologically verified myocarditis; 18 patients with primary cardiomyopathy (control group). All patients underwent full clinical evaluation, endomyocardial biopsy (including immunohistochemical analysis). Forty (54 %) patients underwent radiofrequency catheter ablation of VT. An implantable cardioverter-defibrillator (ICD) was inserted in 17 patients. Results. There was no statistically significant difference between myocarditis and primary cardiomyopathy groups by demographic and echocardiographic data. In myocarditis group, nonsustained VT and/or frequent premature ventricular beats were seen in 59 % of patients; sustained VT in 12,5 % subjects, 1 patient had a history of ventricular fibrillation. VT ablation was associated with a significant decrease in VT recurrence (p=0,0009) during the follow-up period. Active myocarditis was associated with a higher VT recurrence rate (67 % in active vs. 19 % in borderline myocarditis). Among patients with ICD implantation, only one subject (with active myocarditis at admission) had life-threatening ventricular arrhythmia. Conclusion. In this selected group of patients with verified myocarditis and clinically significant VTs, catheter ablation seems at least partly effective. Patients with borderline myocarditis and symptomatic VTs may benefit from ablation. Therefore, morphological diagnostic of myocarditis can be a key point in choice of treatment.
  1. Kühl U, Pauschinger M, Noutsias M, Seeberg B, Bock T, Lassner D et al. High prevalence of viral genomes and multiple viral infections in the myocardium of adults with “idiopathic” left ventricular dysfunction. Circulation. 2005;111 (7):887–93. DOI:10.1161/01.CIR.0000155616.07901.35.
  2. Drory Y, Turetz Y, Hiss Y, Lev B, Fisman EZ, Pines A et al. Sudden unexpected death in persons less than 40 years of age. Am J Cardiol. 1991;68 (13):1388–92.
  3. Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN et al. Sudden death in young adults: a 25‑year review of autopsies in military recruits. Ann Intern Med. 2004;141(11):829–34.
  4. Frustaci A, Bellocci F, Olsen EG. Results of biventricular endomyocardial biopsy in survivors of cardiac arrest with apparently normal hearts. Am J Cardiol. 1994;74 (9):890–5.
  5. Wojnicz R, Nowalany-Kozielska E, Wodniecki J, Szczurek-Katański K, Nozyński J, Zembala M et al. Immunohistological diagnosis of myocarditis. Potential role of sarcolemmal induction of the MHC and ICAM-1 in the detection of autoimmune mediated myocyte injury. Eur Heart J. 1998;19 (10):1564–72.
  6. Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U 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 Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. Eur Heart J. 2007;28(24):3076–93. DOI:10.1093/eurheartj/ehm456.
  7. Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2015;36 (41):2793–867. DOI:10.1093/eurheartj/ehv316.
  8. Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12 (8):767–78. DOI:10.1093/eurjhf/hfq120.
  9. Pinto YM, Elliott PM, Arbustini E, Adler Y, Anastasakis A, Böhm M et al. Proposal for a revised definition of dilated cardiomyopathy, hypokinetic non-dilated cardiomyopathy, and its implications for clinical practice: a position statement of the ESC working group on myocardial and pericardial diseases. Eur Heart J. 2016;37(23):1850–8. DOI:10.1093/eurheartj/ehv727.
  10. Zipes DP, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. Sixth edition. Philadelphia, PA: Elsevier/Saunders; 2014. 1365 p.
  11. Pieroni M, Smaldone C, Bellocci F. Myocarditis Presenting with Ventricular Arrhythmias: Role of Electroanatomical Mapping-Guided Endomyocardial Biopsy in Differential Diagnosis. In: Cihakova D, editor. Myocarditis [Internet]. InTech; 2011 [cited 2017]. Available from: http://www.intechopen.com/books/myocarditis/myocarditis-presenting-with-ventricular-arrhythmiasrole-of-electroanatomical-mapping-guided-endomyo.
  12. Saito J, Niwano S, Niwano H, Inomata T, Yumoto Y, Ikeda K et al. Electrical remodeling of the ventricular myocardium in myocarditis: studies of rat experimental autoimmune myocarditis. Circ J. 2002;66 (1):97–103.
  13. Badorff C, Lee GH, Lamphear BJ, Martone ME, Campbell KP, Rhoads RE et al. Enteroviral protease 2A cleaves dystrophin: evidence of cytoskeletal disruption in an acquired cardiomyopathy. Nat Med. 1999;5 (3):320–6. DOI:10.1038/6543.
  14. Baksi AJ, Kanaganayagam GS, Prasad SK. Arrhythmias in viral myocarditis and pericarditis. Card Electrophysiol Clin. 2015;7(2):269–81. DOI:10.1016/j.ccep.2015.03.009.
  15. Cohn JN, Ferrari R, Sharpe N. Cardiac remodeling - concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an International Forum on Cardiac Remodeling. J Am Coll Cardiol. 2000;35 (3):569–82.
  16. Kuan AP, Chamberlain W, Malkiel S, Lieu HD, Factor SM, Diamond B et al. Genetic control of autoimmune myocarditis mediated by myosin-specific antibodies. Immunogenetics. 1999;49(2):79–85.
  17. Wiltshire SA, Leiva-Torres GA, Vidal SM. Quantitative trait locus analysis, pathway analysis, and consomic mapping show genetic variants of Tnni3k, Fpgt, or H28 control susceptibility to viral myocarditis. J Immunol. 2011;186 (11):6398–405. DOI:10.4049/jimmunol.1100159.
  18. Lazzerini PE, Capecchi PL, Laghi-Pasini F, Boutjdir M. Autoimmune channelopathies as a novel mechanism in cardiac arrhythmias. Nat Rev Cardiol. 2017;14 (9):521–35. DOI:10.1038/nrcardio.2017.61.
  19. Митрофанова Л. Б., Маликов К. Н., Лебедев Д. С., Зверев Д. А., Моисеева О. М. Аутоиммунная кардиомиопатия: миф или реальность? Журнал Сердечная Недостаточность. 2015;16 (5 (92)):288–95. DOI:10.18087/rhfj.2015.5.2105 [Mitrofanova L. B., Malikov K. N., Lebedev D. S., Zverev D. A., Moiseeva O. M. Autoimmunnaya kardiomiopatiya: mif ili real`nost`? Zhurnal Serdechnaya Nedostatochnost`. 2015;16 (5 (92)): 288–95. DOI: 10.18087/rhfj.2015.5.2105].
  20. Corrado D, Basso C, Leoni L, Tokajuk B, Bauce B, Frigo G et al. Three-dimensional electroanatomic voltage mapping increases accuracy of diagnosing arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circulation. 2005;111 (23):3042–50. DOI:10.1161/CIRCULATIONAHA.104.486977.
  21. Pieroni M, Dello Russo A, Marzo F, Pelargonio G, Casella M, Bellocci F et al. High prevalence of myocarditis mimicking arrhythmogenic right ventricular cardiomyopathy differential diagnosis by electroanatomic mapping-guided endomyocardial biopsy. J Am Coll Cardiol. 2009;53 (8):681–9. DOI:10.1016/j.jacc.2008.11.017.
  22. Михайлов Е. Н., Татарский Р. Б., Митрофанова Л. Б., Лебедев Д. С. «Прицельная» эндомиокардиальная биопсия в диагностике аритмогенной дисплазии правого желудочка у пациентов, направленных на катетерную аблацию желудочковых аритмий. Российский Кардиологический Журнал. 2016;(7 (135)): 88–92 [Mixajlov E. N., Tatarskij R. B., Mitrofanova L. B., Lebedev D. S. “Priczel`naya” e`ndomiokardial`naya biopsiya v diagnostike aritmogennoj displazii pravogo zheludochka u paczientov, napravlenny`x na kateternuyu ablacziyu zheludochkovy`x aritmij. Rossijskij Kardiologicheskij Zhurnal. 2016; (7 (135)): 88–92].
  23. Gradman A, Deedwania P, Cody R, Massie B, Packer M, Pitt B et al. Predictors of total mortality and sudden death in mild to moderate heart failure. Captopril-Digoxin Study Group. J Am Coll Cardiol. 1989;14 (3):564–570; discussion 571–572.
  24. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352 (3):225–37. DOI:10.1056/NEJMoa043399.
  25. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350 (21):2140–50. DOI:10.1056/NEJMoa032423.
  26. Kadish A, Dyer A, Daubert JP, Quigg R, Estes NAM, Anderson KP et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med. 2004;350(21):2151–8. DOI:10.1056/NEJMoa033088.
  27. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable Defibrillators for the Prevention of Mortality in Patients With Nonischemic Cardiomyopathy: A Meta-analysis of Randomized Controlled Trials. JAMA. 2004;292 (23):2874–9. DOI:10.1001/jama.292.23.2874.
  28. Anzini M, Merlo M, Sabbadini G, Barbati G, Finocchiaro G, Pinamonti B et al. Long-term evolution and prognostic stratification of biopsy-proven active myocarditis. Circulation. 2013;128(22):2384–94. DOI:10.1161/CIRCULATIONAHA.113.003092.
  29. Lenarczyk R, Potpara TS, Haugaa KH, Hernández-Madrid A, Sciaraffia E, Dagres N et al. The use of wearable cardioverter-defibrillators in Europe: results of the European Heart Rhythm Association survey. Europace. 2016;18 (1):146–50. DOI:10.1093/europace/euw003.
  30. Sasaki S, Tomita H, Shibutani S, Izumiyama K, Higuma T, Itoh T et al. Usefulness of the wearable cardioverter-defibrillator in patients at high risk for sudden cardiac death. Circ J. 2014;78(12):2987–9.
  31. Narducci ML, Rio T, Perna F, D’Amario D, Merlino B, Marano R et al. A Challenging Case Of Ventricular Arrhythmia In A Patient With Myocarditis: ICD Yes / No After Ablation. J Atr Fibrillation. 2014;7 (3):1121. DOI:10.4022/jafib.1121.
  32. Грохотова В. В., Татарский Р. Б., Лебедев Д. С., Лебедева В. К., Митрофанова Л. Б., Пахомов А. В. и др. Катетерная аблация некоронарогенных желудочковых тахиаритмий – ранняя и отдаленная эффективность процедуры в зависимости от этиологии нарушений ритма. Сердце: журнал для практикующих врачей. 2014;13 (1):3–10 [Groxotova V. V., Tatarskij R. B., Lebedev D. S., Lebedeva V. K., Mitrofanova L. B., Paxomov A. V. i dr. Kateternaya ablacziya nekoronarogenny`x zheludochkovy`x taxiaritmij – rannyaya i otdalennaya e`ffektivnost` proczedury` v zavisimosti ot e`tiologii narushenij ritma. Serdcze: zhurnal dlya praktikuyushhix vrachej. 2014;13 (1):3–10].
  33. Cecchi E, Fatucchi S, Crudeli E, Giglioli C. Role of electrophysiological study and catheter ablation for recurrent ventricular tachycardia complicating myocarditis. Acta Medica (Hradec Kralove). 2012;55 (2):96–9. DOI:10.14712/18059694.2015.63.
  34. Dello Russo A, Casella M, Pieroni M, Pelargonio G, Bartoletti S, Santangeli P et al. Drug-refractory ventricular tachycardias after myocarditis: endocardial and epicardial radiofrequency catheter ablation. Circ Arrhythm Electrophysiol. 2012;5 (3):492–8. DOI: 10.1161/CIRCEP.111.965012.
  35. Kettering K, Kampmann C, Mollnau H, Kreitner K-F, Münzel T, Weiss C. Catheter ablation of an incessant ventricular tachycardia originating from the left aortic sinus cusp in an adolescent with subacute myocarditis. Clin Res Cardiol. 2009;98 (1):66–70. DOI: 10.1007/s00392‑008‑0717‑y.
  36. Maccabelli G, Tsiachris D, Silberbauer J, Esposito A, Bisceglia C, Baratto F et al. Imaging and epicardial substrate ablation of ventricular tachycardia in patients late after myocarditis. Europace. 2014;16 (9):1363–72. DOI:10.1093/europace/euu017.
  37. Mazzone P, Tsiachris D, Della Bella P. Epicardial management of myocarditis-related ventricular tachycardia. Eur Heart J. 2013;34(3):244. DOI:10.1093/eurheartj/ehs316.
  38. Zeppenfeld K, Blom NA, Bootsma M, Schalij MJ. Incessant ventricular tachycardia in fulminant lymphocytic myocarditis: Evidence for origin in the Purkinje system and successful treatment with ablation. Heart Rhythm. 2007;4 (1):88–91. DOI:10.1016/j.hrthm.2006.09.002.
  39. Combes A. [Acute myocarditis]. Rev Prat. 2013;63 (5):611–6.
  40. Shauer A, Gotsman I, Keren A, Zwas DR, Hellman Y, Durst R et al. Acute viral myocarditis: current concepts in diagnosis and treatment. Isr Med Assoc J. 2013;15 (3):180–5.
Syrovnev V. A., Lebedev D. S., Mitrofanova L. B., Lebedeva V. K., Tatarsky R. B., Mikhaylov E. N., Moiseeva O. M. Interventional treatment in patients with myocarditis: Pro and Contra. Kardiologiia. 2017;57(S3):49–56

To access this material please log in or register

Register Authorize
Ru En