MYOCARDITIS

SOLEIMAN ARIA
CARDIOLOGY REGISTRAR
JMO TEACHING
CASE PRESENTATION

• 19 year old female

• Presented with atypical chest pain
• ECG: Non specific ST-T wave changes
• Troponin 10,000
• Echocardiogram: Normal LV size and Fx, Mild hypertrophy of LV, Normal RV Size and fx
• Started to become hypotensive 11pm
• Unresponsive to Inotropes
• Passed away by 2 am
DEFINITION

• Myocarditis (WHO 1995, AHA 2016, ESC 2013):

• An inflammatory disease of the myocardium and is diagnosed by:
• Established histological, immunological and immunohistochemical criteria
• Histological features (Dallas criteria on EMB)

• Complications of EMB:
• Perforation / Tamponade
• Arrhythmias
• Death
CLINICAL PRESENTATION

• Symptoms
• Atypical chest pain, pseudo-ischaemic, pericarditic, SOB, palpitations, Syncope, Cardiogenic
Shock and Sudden Cardiac Death
• Onset of symptoms from days up to several years

• ECG abnormalities
• Conduction disturbances, ST-T changes, VT, VF

• Biomarkers
• Troponin, BNP, CK-MB
• CRP, ESR
4 PATTERNS OF CLINICAL PRESENTATION

1. Acute Coronary Syndrome Like

1. Chest pain, 1-4 / 52 post a respiratory or gastrointestinal infection

2. New onset or worsening heart failure in the absence of CAD / known Heart Failure
3. Chronic Heart Failure in the absence of CAD or other known causes of Heart Failure
1. 9-16% of unexplained DCM

4. Life threatening conditions

1. VT, VF, SCD, Cardiogenic Shock
1. In Australia 12% of Autopsies on unexplained SCD has shown myocarditis
2. Severely impaired LV dysfunction
DEMOGRAPHICS AND INCIDENCE

• Reported Worldwide Incidence is 22 per 100,000

• Actual incidence is most likely higher
• More prevalent in men who are also affected more severely
PATHOGENESIS
PATHOGENESIS

• Four different classifications

• Fulminant (Rapid Progressive Myocarditis)
• Acute myocarditis
• Chronic active myocarditis
• Chronic persistent myocarditis
FULMINANT VS NON-FULMINANT
MYOCARDITIS
AETIOLOGIES

• Infectious
• Immune mediated
• Toxins / Drugs
• Idiopathic
DIAGNOSIS

• Clinical history and Examination

• ECG:
• Neither specific nor sensitive

• Exclusion of CAD
• Non-invasive imaging techniques
• Echocardiography
• MRI
DIAGNOSIS

• Endomyocardial Biopsy is the Gold Standard

• Myocarditis (WHO 1995, AHA 2016, ESC 2013):
• An inflammatory disease of the myocardium and is diagnosed by:
• Established histological, immunological and immunohistochemical criteria
• Histological features (Dallas criteria on EMB)

• Electro-anatomic mapping guided endomyocardial biopsy

• Complications of EMB:
• Perforation / Tamponade
• Arrhythmias
• Death
EMB-GUIDED THERAPY
MANAGEMENT AND PROGNOSIS

• Acute Myocarditis:
• Resolves in about 50% of cases
• 25% will develop persistent LV dysfuction
• 12-25% will acutely deteriorate and either die or progress to end-stage DCM / heart transplant

• Patients with life-threatening presentation:

• Haemodynamic monitoring, Catheterization, EMB
• Mechanical cardio-pulmonary assist device as a bridge to recovery / transplantation
• Transplantation should be deferred as recovery may occur
MANAGEMENT AND PROGNOSIS

• Arrythmias:
• ICD implantation should be deferred
• Otherwise treated based on the guidelines

• Avoidance of exercise:
• Restricted physical activity until full recovery
• Athletes should restrict exercise for 6 months

• Immunotherapy:
• Immunosuppression should be started only after ruling out active infection on EMB.
• For giant cell myocarditis, cardiac sarcoidosis, and autoimmune myocarditis
LV SUICIDE POST
TAVI
HAEMODYNAMIC COLLAPSE POST TAVI

• Coronary Patency
• Ilio-femoral integrity
• Annular Root injury
• Valve Failure
• Ventricular Perforation
• Tamponade Mitral Valve Injury
• Suicide Ventricle
SUICIDE VENTRICLE POST TAVI

• 82 year old with Severe AS was admitted for TAVI

• MG of 83mmHg, AVA 0.35cm2
• Hyperdynamic LV EF 79%, SW 17mm, PW 14mm

• Next morning
• Reduced urine out put (25-30ml/hr) : IV Furosemide
• Became hypotensive : Noradrenaline was started
• Paradoxical effect and became more hypotensive
• Developed anterior STEMI
• Cathlab:
SUICIDE VENTRICLE POST TAVI

• CAG: No obstructive CAD

• LV gram:
• HOCM Physiology
• Responded to
• Intravenous Hydration
• Betablockers
SUICIDE VENTRICLE POST TAVI
QUESITONS