Effect of Acute Immunosuppression on Left Ventricular Recovery and Mortality in Fulminant Viral Myocarditis: A Case Series and Review of Literature

Abstract

Background Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies. Methods We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM. Results We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery. Conclusions Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

“…The rationale for the MYTHS trial is based on clinical practice. Indeed, several case series and case reports support the effectiveness of high dosage corticosteroids ( 48 – 50 ).…”

Acute Myocarditis Following mRNA-1273 SARS-CoV-2 Vaccination

“…The gold standard for diagnosis is via histopathological sampling with endomyocardial biopsy, however, this is not always feasible or practical. A probable diagnosis can be achieved in the appropriate clinical context with elevated cardiac enzymes as well as functional and structural abnormalities on cardiac echocardiogram and MRI [1] .…”

Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam

“…The strongest evidence for immunosuppressive therapy occurs in cardiac sarcoidosis, giant-cell myocarditis, and autoimmune rheumatic disease ( 22 – 24 ). However, recent studies in adults and pediatrics reported that immunosuppressive therapy with IVIG and/or high dose methylprednisolone was associated with rapid LVEF recovery, short duration of ECMO support, and low mortality rate in fulminant myocarditis ( 25 , 26 ). Nevertheless, further well-designed studies are required to investigate this issue in the pediatric population.…”