Chinese expert consensus statement on the diagnosis and treatment of fulminant myocarditis
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摘要
Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock,with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial(NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time,we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes(i) mechanical life support(applications of mechanical respirators and circulatory support systems,including intraaortic balloon pump and extracorporeal membrane oxygenation),(ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and(iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock,with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial(NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time,we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes(i) mechanical life support(applications of mechanical respirators and circulatory support systems,including intraaortic balloon pump and extracorporeal membrane oxygenation),(ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and(iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock,with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial(NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time,we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes(i) mechanical life support(applications of mechanical respirators and circulatory support systems,including intraaortic balloon pump and extracorporeal membrane oxygenation),(ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and(iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
引文
Badawy,S.S.I.,and Fahmy,A.(2012).Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure:a randomized comparative study.JCritical Care 27,106.e7-106.e13.
Bjelakovic,B.,Vukomanovic,V.,and Jovic,M.(2016).Fulminant myocarditis in children successfully treated with high dose of methylprednisolone.Ind J Pediatr 83,268-269.
Bulut,D.,Scheeler,M.,Wichmann,T.,B?rgel,J.,Miebach,T.,and Mügge,A.(2010).Effect of protein A immunoadsorption on T cell activation in patients with inflammatory dilated cardiomyopathy.Clin Res Cardiol99,633-638.
Caforio,A.L.P.,Pankuweit,S.,Arbustini,E.,Basso,C.,Gimeno-Blanes,J.,Felix,S.B.,Fu,M.,Heli?,T.,Heymans,S.,Jahns,R.,et al.(2013).Current state of knowledge on aetiology,diagnosis,management,and therapy of myocarditis:a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.Eur Heart J 34,2636-2648.
Caforio,A.L.P.,Malipiero,G.,Marcolongo,R.,and Iliceto,S.(2017).Myocarditis:A clinical overview.Curr Cardiol Rep 19,63.
Chen,H.S.,Wang,W.,Wu,S.N.,and Liu,J.P.(2013).Corticosteroids for viral myocarditis.Cochrane Database Syst Rev 20.
Chen,J.,Lai,J.,Yang,L.,Ruan,G.,Chaugai,S.,Ning,Q.,Chen,C.,and Wang,D.W.(2016).Trimetazidine prevents macrophage-mediated septic myocardial dysfunction via activation of the histone deacetylase sirtuin 1.British J Pharmacol 173,545-561.
Diddle,J.W.,Almodovar,M.C.,Rajagopal,S.K.,Rycus,P.T.,and Thiagarajan,R.R.(2015).Extracorporeal membrane oxygenation for the support of adults with acute myocarditis.Critical Care Med 43,1016-1025.
Drucker,N.A.,Colan,S.D.,Lewis,A.B.,Beiser,A.S.,Wessel,D.L.,Takahashi,M.,Baker,A.L.,Perez-Atayde,A.R.,and Newburger,J.W.(1994).Gamma-globulin treatment of acute myocarditis in the pediatric population..Circulation 89,252-257.
Felix,S.B.,Beug,D.,and D?rr,M.(2015).Immunoadsorption therapy in dilated cardiomyopathy.Expert Rev Cardiovasc Ther 13,145-152.
Felker,G.M.,Boehmer,J.P.,Hruban,R.H.,Hutchins,G.M.,Kasper,E.K.,Baughman,K.L.,and Hare,J.M.(2000).Echocardiographic findings in fulminant and acute myocarditis.J Am College Cardiol 36,227-232.
Fung,G.,Luo,H.,Qiu,Y.,Yang,D.,and McManus,B.(2016).Myocarditis.Circ Res 118,496-514.
Ginsberg,F.,and Parrillo,J.E.(2013).Fulminant myocarditis.Crit Care Clin 29,465-483.
Goland,S.,Czer,L.S.C.,Siegel,R.J.,Tabak,S.,Jordan,S.,Luthringer,D.,Mirocha,J.,Coleman,B.,Kass,R.M.,and Trento,A.(2008).Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy:series of six patients and review of literature.Can J Cardiol 24,571-574.
Gupta,S.,Markham,D.W.,Drazner,M.H.,and Mammen,P.P.(2008).Fulminant myocarditis.Nat Rev Cardiol 5,693-706.
Hsu,K.H.,Chi,N.H.,Yu,H.Y.,Wang,C.H.,Huang,S.C.,Wang,S.S.,Ko,W.J.,and Chen,Y.S.(2011)Extracorporeal membranous oxygenation support for acute fulminant myocarditis:analysis of a single center’s experience.Eur J Cardio-Thoracic Surg.
Hu,W.,Liu,C.,Hu,W.,Lu,J.,Zhu,Y.,Wang,J.,and Liu,B.(2014).Analysis of 5 cases of treating fulminant myocarditis with ECMO.Chin J Crit Care Med(Electronical Eition)7,4.
Hufnagel,G.,Pankuweit,S.,Richter,A.,Schonian,U.,Maisch,B.(2000).The European Study of Epidemiology and Treatment of Cardiac Inflammatory Diseases(ESETCID).First epidemiological results.Herz25,279-285.
Ihdayhid,A.R.,Chopra,S.,and Rankin,J.(2014).Intra-aortic balloon pump.Curr Opin Cardiol 29,285-292.
Isogai,T.,Yasunaga,H.,Matsui,H.,Tanaka,H.,Horiguchi,H.,and Fushimi,K.(2015).Effect of intravenous immunoglobulin for fulminant myocarditis on in-hospital mortality:propensity score analyses.J Cardiac Failure 21,391-397.
Jensen,L.D.,and Marchant,D.J.(2016).Emerging pharmacologic targets and treatments for myocarditis.Pharmacol Therapeutics 161,40-51.
Kishimoto,C.,Shioji,K.,Hashimoto,T.,Nonogi,H.,Lee,J.D.,Kato,S.,Hiramitsu,S.,and Morimoto,S.(2014).Therapy with immunoglobulin in patients with acute myocarditis and cardiomyopathy:analysis of leukocyte balance.Heart Vessels 29,336-342.
Kühl,U.,Lassner,D.,von Schlippenbach,J.,Poller,W.,and Schultheiss,H.P.(2012).Interferon-beta improves survival in enterovirus-associated cardiomyopathy.J Am College Cardiol 60,1295-1296.
Lazaros,G.,Oikonomou,E.,and Tousoulis,D.(2017).Established and novel treatment options in acute myocarditis,with or without heart failure.Expert Rev Cardiovasc Ther 15,25-34.
Lorusso,R.,Centofanti,P.,Gelsomino,S.,Barili,F.,Di Mauro,M.,Orlando,P.,Botta,L.,Milazzo,F.,Actis Dato,G.,Casabona,R.,et al.(2016).Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients:A 5-year multi-institutional experience.Ann Thoracic Surg 101,919-926.
Luyt,C.E.,Hékimian,G.,and Ginsberg,F.(2016).What’s new in myocarditis?Intensive Care Med 42,1055-1057.
Luyt,C.E.,Landivier,A.,Leprince,P.,Bernard,M.,Pavie,A.,Chastre,J.,and Combes,A.(2012).Usefulness of cardiac biomarkers to predict cardiac recovery in patients on extracorporeal membrane oxygenation support for refractory cardiogenic shock.J Critical Care 27,524.e7-524.e14.
Maisch,B.,Ruppert,V.,and Pankuweit,S.(2014).Management of fulminant myocarditis:a diagnosis in search of its etiology but with therapeutic options.Curr Heart Fail Rep 11,166-177.
McCarthy,R.E.,Boehmer,J.P.,Hruban,R.H.,Hutchins,G.M.,Kasper,E.K.,Hare,J.M.,and Baughman,K.L.(2000).Long-term outcome of fulminant myocarditis as compared with acute(nonfulminant)myocarditis.N Engl J Med 342,690-695.
Nakamura,T.,Ishida,K.,Taniguchi,Y.,Nakagawa,T.,Seguchi,M.,Wada,H.,Sugawara,Y.,Funayama,H.,Mitsuhashi,T.,and Momomura,S.I.(2015).Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support:a retrospective single-center study.J Intensive Care 3,5.
Okai,I.,Inoue,K.,Maruyama,M.,Maruyama,S.,Komatsu,K.,Nishizawa,H.,Okazaki,S.,Fujiwara,Y.,Sumiyoshi,M.,and Daida,H.(2012).Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis.Heart Vessels 27,639-642.
Pollack,A.,Kontorovich,A.R.,Fuster,V.,and Dec,G.W.(2015).Viral myocarditis-diagnosis,treatment options and current controversies.Nat Rev Cardiol 12,670-680.
Pozzi,M.,Banfi,C.,Grinberg,D.,Koffel,C.,Bendjelid,K.,Robin,J.,Giraud,R.,and Obadia,J.F.(2016).Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock due to myocarditis in adult patients.J Thorac Dis 8,E495-E502.
Schmidt,M.,Burrell,A.,Roberts,L.,Bailey,M.,Sheldrake,J.,Rycus,P.T.,Hodgson,C.,Scheinkestel,C.,Cooper,D.J.,Thiagarajan,R.R.,et al.(2015).Predicting survival after ECMO for refractory cardiogenic shock:the survival after veno-arterial-ECMO(SAVE)-score.Eur Heart J 36,2246-2256.
Sun,D.,Ding,H.,Zhao,C.,Li,Y.,Wang,J.,Yan,J.,and Wang,D.W.(2017).Value of SOFA,APACHE IV and SAPS II scoring systems in predicting short-term mortality in patients with acute myocarditis.Oncotarget 8.
Tang,L.,and Zhu,Y.(2014).36 cases of fulminant myocarditis in children.Chongqing Med,4241-4242.
Wang,Y.,Yuan,Y.,Qin,W.,Wei,S.,and Cui,L.(2013).Sixty-four cases of fulminant myocarditis in children.Chin J Pract Pediatr 28,3.
Yang,G.,Ding,J.,Guan,M.,Zhang,D.,Ding,M.,Gu,R.,Sun,Y.,Xu,G.,Peng,C.,and Han,Y.(2016).Experiences of treating fulminant myocarditis with multiple organ failure.Clin J Med Offic 44,3.
Yu,D.Q.,Wang,Y.,Ma,G.Z.,Xu,R.H.,Cai,Z.X.,Ni,C.M.,Chen,P.,and Zhu,Z.D.(2014).Intravenous immunoglobulin in the therapy of adult acute fulminant myocarditis:A retrospective study.Exp Therapeutic Med 7,97-102.
Bjelakovic,B.,Vukomanovic,V.,and Jovic,M.(2016).Fulminant myocarditis in children successfully treated with high dose of methylprednisolone.Ind J Pediatr 83,268-269.
Bulut,D.,Scheeler,M.,Wichmann,T.,B?rgel,J.,Miebach,T.,and Mügge,A.(2010).Effect of protein A immunoadsorption on T cell activation in patients with inflammatory dilated cardiomyopathy.Clin Res Cardiol99,633-638.
Caforio,A.L.P.,Pankuweit,S.,Arbustini,E.,Basso,C.,Gimeno-Blanes,J.,Felix,S.B.,Fu,M.,Heli?,T.,Heymans,S.,Jahns,R.,et al.(2013).Current state of knowledge on aetiology,diagnosis,management,and therapy of myocarditis:a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.Eur Heart J 34,2636-2648.
Caforio,A.L.P.,Malipiero,G.,Marcolongo,R.,and Iliceto,S.(2017).Myocarditis:A clinical overview.Curr Cardiol Rep 19,63.
Chen,H.S.,Wang,W.,Wu,S.N.,and Liu,J.P.(2013).Corticosteroids for viral myocarditis.Cochrane Database Syst Rev 20.
Chen,J.,Lai,J.,Yang,L.,Ruan,G.,Chaugai,S.,Ning,Q.,Chen,C.,and Wang,D.W.(2016).Trimetazidine prevents macrophage-mediated septic myocardial dysfunction via activation of the histone deacetylase sirtuin 1.British J Pharmacol 173,545-561.
Diddle,J.W.,Almodovar,M.C.,Rajagopal,S.K.,Rycus,P.T.,and Thiagarajan,R.R.(2015).Extracorporeal membrane oxygenation for the support of adults with acute myocarditis.Critical Care Med 43,1016-1025.
Drucker,N.A.,Colan,S.D.,Lewis,A.B.,Beiser,A.S.,Wessel,D.L.,Takahashi,M.,Baker,A.L.,Perez-Atayde,A.R.,and Newburger,J.W.(1994).Gamma-globulin treatment of acute myocarditis in the pediatric population..Circulation 89,252-257.
Felix,S.B.,Beug,D.,and D?rr,M.(2015).Immunoadsorption therapy in dilated cardiomyopathy.Expert Rev Cardiovasc Ther 13,145-152.
Felker,G.M.,Boehmer,J.P.,Hruban,R.H.,Hutchins,G.M.,Kasper,E.K.,Baughman,K.L.,and Hare,J.M.(2000).Echocardiographic findings in fulminant and acute myocarditis.J Am College Cardiol 36,227-232.
Fung,G.,Luo,H.,Qiu,Y.,Yang,D.,and McManus,B.(2016).Myocarditis.Circ Res 118,496-514.
Ginsberg,F.,and Parrillo,J.E.(2013).Fulminant myocarditis.Crit Care Clin 29,465-483.
Goland,S.,Czer,L.S.C.,Siegel,R.J.,Tabak,S.,Jordan,S.,Luthringer,D.,Mirocha,J.,Coleman,B.,Kass,R.M.,and Trento,A.(2008).Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy:series of six patients and review of literature.Can J Cardiol 24,571-574.
Gupta,S.,Markham,D.W.,Drazner,M.H.,and Mammen,P.P.(2008).Fulminant myocarditis.Nat Rev Cardiol 5,693-706.
Hsu,K.H.,Chi,N.H.,Yu,H.Y.,Wang,C.H.,Huang,S.C.,Wang,S.S.,Ko,W.J.,and Chen,Y.S.(2011)Extracorporeal membranous oxygenation support for acute fulminant myocarditis:analysis of a single center’s experience.Eur J Cardio-Thoracic Surg.
Hu,W.,Liu,C.,Hu,W.,Lu,J.,Zhu,Y.,Wang,J.,and Liu,B.(2014).Analysis of 5 cases of treating fulminant myocarditis with ECMO.Chin J Crit Care Med(Electronical Eition)7,4.
Hufnagel,G.,Pankuweit,S.,Richter,A.,Schonian,U.,Maisch,B.(2000).The European Study of Epidemiology and Treatment of Cardiac Inflammatory Diseases(ESETCID).First epidemiological results.Herz25,279-285.
Ihdayhid,A.R.,Chopra,S.,and Rankin,J.(2014).Intra-aortic balloon pump.Curr Opin Cardiol 29,285-292.
Isogai,T.,Yasunaga,H.,Matsui,H.,Tanaka,H.,Horiguchi,H.,and Fushimi,K.(2015).Effect of intravenous immunoglobulin for fulminant myocarditis on in-hospital mortality:propensity score analyses.J Cardiac Failure 21,391-397.
Jensen,L.D.,and Marchant,D.J.(2016).Emerging pharmacologic targets and treatments for myocarditis.Pharmacol Therapeutics 161,40-51.
Kishimoto,C.,Shioji,K.,Hashimoto,T.,Nonogi,H.,Lee,J.D.,Kato,S.,Hiramitsu,S.,and Morimoto,S.(2014).Therapy with immunoglobulin in patients with acute myocarditis and cardiomyopathy:analysis of leukocyte balance.Heart Vessels 29,336-342.
Kühl,U.,Lassner,D.,von Schlippenbach,J.,Poller,W.,and Schultheiss,H.P.(2012).Interferon-beta improves survival in enterovirus-associated cardiomyopathy.J Am College Cardiol 60,1295-1296.
Lazaros,G.,Oikonomou,E.,and Tousoulis,D.(2017).Established and novel treatment options in acute myocarditis,with or without heart failure.Expert Rev Cardiovasc Ther 15,25-34.
Lorusso,R.,Centofanti,P.,Gelsomino,S.,Barili,F.,Di Mauro,M.,Orlando,P.,Botta,L.,Milazzo,F.,Actis Dato,G.,Casabona,R.,et al.(2016).Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients:A 5-year multi-institutional experience.Ann Thoracic Surg 101,919-926.
Luyt,C.E.,Hékimian,G.,and Ginsberg,F.(2016).What’s new in myocarditis?Intensive Care Med 42,1055-1057.
Luyt,C.E.,Landivier,A.,Leprince,P.,Bernard,M.,Pavie,A.,Chastre,J.,and Combes,A.(2012).Usefulness of cardiac biomarkers to predict cardiac recovery in patients on extracorporeal membrane oxygenation support for refractory cardiogenic shock.J Critical Care 27,524.e7-524.e14.
Maisch,B.,Ruppert,V.,and Pankuweit,S.(2014).Management of fulminant myocarditis:a diagnosis in search of its etiology but with therapeutic options.Curr Heart Fail Rep 11,166-177.
McCarthy,R.E.,Boehmer,J.P.,Hruban,R.H.,Hutchins,G.M.,Kasper,E.K.,Hare,J.M.,and Baughman,K.L.(2000).Long-term outcome of fulminant myocarditis as compared with acute(nonfulminant)myocarditis.N Engl J Med 342,690-695.
Nakamura,T.,Ishida,K.,Taniguchi,Y.,Nakagawa,T.,Seguchi,M.,Wada,H.,Sugawara,Y.,Funayama,H.,Mitsuhashi,T.,and Momomura,S.I.(2015).Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support:a retrospective single-center study.J Intensive Care 3,5.
Okai,I.,Inoue,K.,Maruyama,M.,Maruyama,S.,Komatsu,K.,Nishizawa,H.,Okazaki,S.,Fujiwara,Y.,Sumiyoshi,M.,and Daida,H.(2012).Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis.Heart Vessels 27,639-642.
Pollack,A.,Kontorovich,A.R.,Fuster,V.,and Dec,G.W.(2015).Viral myocarditis-diagnosis,treatment options and current controversies.Nat Rev Cardiol 12,670-680.
Pozzi,M.,Banfi,C.,Grinberg,D.,Koffel,C.,Bendjelid,K.,Robin,J.,Giraud,R.,and Obadia,J.F.(2016).Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock due to myocarditis in adult patients.J Thorac Dis 8,E495-E502.
Schmidt,M.,Burrell,A.,Roberts,L.,Bailey,M.,Sheldrake,J.,Rycus,P.T.,Hodgson,C.,Scheinkestel,C.,Cooper,D.J.,Thiagarajan,R.R.,et al.(2015).Predicting survival after ECMO for refractory cardiogenic shock:the survival after veno-arterial-ECMO(SAVE)-score.Eur Heart J 36,2246-2256.
Sun,D.,Ding,H.,Zhao,C.,Li,Y.,Wang,J.,Yan,J.,and Wang,D.W.(2017).Value of SOFA,APACHE IV and SAPS II scoring systems in predicting short-term mortality in patients with acute myocarditis.Oncotarget 8.
Tang,L.,and Zhu,Y.(2014).36 cases of fulminant myocarditis in children.Chongqing Med,4241-4242.
Wang,Y.,Yuan,Y.,Qin,W.,Wei,S.,and Cui,L.(2013).Sixty-four cases of fulminant myocarditis in children.Chin J Pract Pediatr 28,3.
Yang,G.,Ding,J.,Guan,M.,Zhang,D.,Ding,M.,Gu,R.,Sun,Y.,Xu,G.,Peng,C.,and Han,Y.(2016).Experiences of treating fulminant myocarditis with multiple organ failure.Clin J Med Offic 44,3.
Yu,D.Q.,Wang,Y.,Ma,G.Z.,Xu,R.H.,Cai,Z.X.,Ni,C.M.,Chen,P.,and Zhu,Z.D.(2014).Intravenous immunoglobulin in the therapy of adult acute fulminant myocarditis:A retrospective study.Exp Therapeutic Med 7,97-102.