Clinical Presentation and Outcome in a Contemporary Cohort of Patients With Acute Myocarditis: Multicenter Lombardy Registry.

BACKGROUND: There is controversy about the outcome of patients with acute myocarditis (AM), and data are lacking on how patients admitted with suspected AM are managed. We report characteristics, in-hospital management, and long-term outcome of patients with AM based on a retrospective multicenter registry from 19 Italian hospitals. METHODS: A total of 684 patients with suspected AM and recent onset of symptoms (<30 days) were screened between May 2001 and February 2017. Patients >70 years of age and those >50 years of age without coronary angiography were excluded. The final study population comprised 443 patients (median age, 34 years; 19.4% female) with AM diagnosed by either endomyocardial biopsy or increased troponin plus edema and late gadolinium enhancement at cardiac magnetic resonance. RESULTS: At presentation, 118 patients (26.6%) had left ventricular ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, whereas 325 (73.4%) had no such complications. Endomyocardial biopsy was performed in 56 of 443 (12.6%), and a baseline cardiac magnetic resonance was performed in 415 of 443 (93.7%). Cardiac mortality plus heart transplantation rates at 1 and 5 years were 3.0% and 4.1%. Cardiac mortality plus heart transplantation rates were 11.3% and 14.7% in patients with complicated presentation and 0% in uncomplicated cases (log-rank P<0.0001). Major AM-related cardiac events after the acute phase (postdischarge death and heart transplantation, sustained ventricular arrhythmias treated with electric shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8% at the 5-year follow-up, with a higher incidence in patients with complicated forms (10.8% versus 0% in uncomplicated AM; log-rank P<0.0001). ß-Adrenoceptor blockers were the most frequently used medications both in complicated (61.9%) and in uncomplicated forms (53.8%; P=0.18). After a median time of 196 days, 200 patients had follow-up cardiac magnetic resonance, and 8 of 55 (14.5%) with complications at presentation had left ventricular ejection fraction <50% compared with 1 of 145 (0.7%) of those with uncomplicated presentation. CONCLUSIONS: In this contemporary study, overall serious adverse events after AM were lower than previously reported. However, patients with left ventricular ejection fraction <50%, ventricular arrhythmias, or low cardiac output syndrome at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent left ventricular systolic dysfunction.

Acute effects of positive end-expiratory pressure on left ventricle diastolic function in healthy subjects.

We evaluated the acute effect of the application of positive end-expiratory pressure (PEEP) on LV diastolic function in 10 healthy subjects. We assessed load dependent diastolic function by Doppler examination of transmitral flow and load independent diastolic function by color M-mode propagation velocity of early flow into the LV cavity (Vp). During the application of PEEP in comparison to the baseline, we found a significant reduction of the E wave peak velocity [79 (64-83) vs. 65 (57-72) cm/s; p = 0.028] and a significant reduction in Vp [84 (73-97) vs. 53 (48-66); p = 0.012]. Moreover, we found a significant reduction in left atrial area [15 (13-18) vs. 12 (10-14) cm(2); p = 0.018] and right atrial area [12 (11-15) vs. 11 (9-12) cm(2); p = 0.015]. No difference was found in global LV systolic function. The application of PEEP acutely modifies the diastolic flow pattern across the mitral valve, and reduces atrial dimensions.

Cardiac papillary fibroelastoma presenting with acute coronary syndrome and syncope.

A 70-year-old female was admitted for syncope preceded by chest pain. On admission ECG showed signs of myocardial ischaemia and cardiac troponin I (cTnI) was mildly elevated. Acute coronary syndrome without ST elevation was diagnosed. During hospitalization transthoracic echocardiography (TTE) revealed the presence of a round echogenic pedunculated mass adherent to the aortic valve. Cardiac catheterization revealed normal coronary arteries. According to the hypothesis that the lesion could be responsible for both acute coronary syndrome and syncope, surgical intervention was scheduled. The mass was removed and the histological examination revealed a cardiac papillary fibroelastoma (CPF). CPF is the most common tumour of the cardiac valves, it is often found incidentally but it can cause myocardial infarction, sudden death, syncope and stroke; its embolization is the most common complication. For symptomatic patients surgical excision is curative.