Management of Acute Myocarditis Ri

Outline of PresentationMedical TreatmentConventional TreatmentImmuno-suppressantsImmuno-modulating therapyMechanical Circulatory SupportPercutaneous cardiopulmonary supportVentricular assist deviceHeart Transplantation

Medical Treatment A Clinical Trial of Immunosuppressive Therapy for Myocarditis. NEJM 1995;333(5): 269~275 Etiology, Evaluation and Management of Acute Myocarditis Cardiol. in Review 2001;9(2): 88~95 Antiinflammatory Therapy in Myocarditis Curr. Opin.Cardiol 2003;18:189~193

Conventional Treatment

Immuno-suppressantsStudy MethodsEnrollmentOnset of HF in 2yrs without CAD or other significant causeLVEF < 45%Biopsy proved lymphocytic myocarditisTherapyStepped regimen of conventional drugs for HFPrednisone + azathioprine for 24 wksPrednisone + cyclosporin for 24 wksEnd PointsPrimary: LV performance (LVEF, PCWP, LV diameter)Secondary: survival

Distinct Form of Myocarditis

Immuno-suppressantsResultsImmunosuppressants did not have benefit on the LV function or improve survivalIndependent predictors of improvement in LV functionBetter base-line LV ejection fractionLess intensive conventional therapy at base-lineShorter duration of disease

Immuno-suppressantsDiscussionDilemma: is myocarditis due to immunity ?Stronger immune response associated with less severe initial diseaseHigher cardiac IgG Ab better LVEFHigher level of NK cells less intensive carePathogenesis of acute myocarditis

Pathogenesis of Acute Myocarditis

Circulation 1999; 99:1091~1100

Conclusion to immunosuppressants Prominent immunologic response may be a benefit rather than a principal cause of myocarditisRoutine use of immunosuppressants is not recommended for patient with stable clinical courseHowever, aggressive immunosuppressants for fulminant myocarditis and/or deterioration clinical course is still controversial.Timing ?What can we do more ?

Immuno-modulating TherapyIVIGNo improvement in LV performance Circulation 2001; 103:2254~2259Immuo-adsorption + sequential IVIGDeplete a variety of circulating Ig and immune complexIg substitutionSignificant improvement in LV function J Am Coll Cardiol 2000; 35:1590~1598

Mechanical Circulatory Support Circulatory Support for Fulminant Myocarditis: Consideration for implantation, weaning and explantation Eur J Cardiothorac Surg.; 2003(24): 399~403 Fulminant Myocarditis in Adults and children: bi-ventricular assist device for recovery Eur J Cardiothorac Surg.; 2004(26): 1169~1173

Indication in Fulminant CasesLife saving approach in patients of fulminant myocarditisConcerned questions:Timing of implantationIntractable cardiogenic shockBefore multi-organ failureDevice selectionPercutaneous cardiopulmonary support (PCPS)Ventricular assist device (VAD)

ECMOAdvantagesEasy to implant and explant, lower costThe support duration to recovery was shorterECMO vs. BiVAD: 5.5 3 ds vs. 10.2 6.1 dsTroponin level as a good indicator for recoveryCan be switched to VAD at any timeDisadvantagesInadequate unloading of the LV

Conclusion to MCSPatients surviving the acute phase crisis of acute myocarditis have a favorable long-term survival rate and LVEF, whether or not mechanical support is used.However, the selection of MCS is still individualized.

Heart Transplantation

Timing and OutcomeTransplantation should be avoided in acute phaseViral myocarditis: potential recovery by conventional therapyAutoimmune: high incidence of recurrence Transplantation in chronic stage (DCM)No significant difference in outcome compared with other causes of HF