Development and Validation of a Prediction Model on Adult Emergency Department Patients for Early Identification of Fulminant Myocarditis

Objective It is difficult to predict fulminant myocarditis at an early stage in the emergency department.The objective of this study was to construct and validate a simple prediction model for the early identification of fulminant myocarditis.Methods A total of 61 patients with fulminant myocarditis and 160 patients with acute myocarditis were enrolled in the training and internal validation cohorts.LASSO regression and multivariate logistic regression were selected to develop the prediction model.The selection of the model was based on overall performance and simplicity.A nomogram based on the optimal model was built,and its clinical usefulness was evaluated by decision curve analysis.The predictive model was further validated in an external validation group.Results The resulting prediction model was based on 4 factors:systolic blood pressure,troponin I,left ventricular ejection fraction,and ventricular wall motion abnormality.The Brier scores of the final model were 0.078 in the training data set and 0.061 in the internal testing data set,respectively.The C-indexes of the training data set and the testing data set were 0.952 and 0.968,respectively.Decision curve analysis showed that the nomogram model developed based on the 4 predictors above had a positive net benefit for predicting probability thresholds.In the external validation cohort,the model also showed good performance(Brier score=0.007,and C-index=0.989).Conclusion We developed and validated an early prediction model consisting of 4 clinical factors(systolic blood pressure,troponin I,left ventricular ejection fraction,and ventricular wall motion abnormality)to identify potential fulminant myocarditis patients in the emergency department.

Risk factors for adverse cardiac events in adults with fulminant myocarditis during hospitalization

BACKGROUND Fulminant myocarditis is the critical form of myocarditis that is often associated with heart failure, malignant arrhythmia, and circulatory failure. Patients with fulminant myocarditis who end up with severe multiple organic failure and death are not rare.AIM To analyze the predictors of in-hospital major adverse cardiovascular events(MACE) in patients diagnosed with fulminant myocarditis.METHODS We included a cohort of adult patients diagnosed with fulminant myocarditis who were admitted to Beijing Anzhen Hospital from January 2007 to December2017. The primary endpoint was defined as in-hospital MACE, including death,cardiac arrest, cardiac shock, and ventricular fibrillation. Baseline demographics,clinical history, characteristics of electrocardiograph and ultrasonic cardiogram,laboratory examination, and treatment were recorded. Multivariable logistic regression was used to examine risk factors for in-hospital MACE, and the variables were subsequently assessed by the area under the receiver operating characteristic curve(AUC).RESULTS The rate of in-hospital MACE was 40%. Multivariable logistic regression analysis revealed that baseline QRS duration > 120 ms was the independent risk factor for in-hospital MACE(odds ratio = 4.57, 95%CI: 1.23-16.94, P = 0.023). The AUC of QRS duration > 120 ms for predicting in-hospital MACE was 0.683(95%CI: 0.532-0.833, P = 0.03).CONCLUSION Patients with fulminant myocarditis has a poor outcome. Baseline QRS duration is the independent risk factor for poor outcome in those patients.

SUCCESSFUL EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT IN A PATIENT WITH FULMINANT MYOCARDITIS

FULMINANT myocarditis complicated with refractory cardiogenic shock carries a very high mortality （76%）. Herein we report our experi-ence in treating a 23-year-old Chinese woman with fulminant myocarditis complicated with cardiogenic shock, who was rescued by extracorporeal membrane oxygenation （ECMO）.

Nursing Strategy for Multidisciplinary Team Comprehensively Treating Three Children with Fulminant Myocarditis

[Objectives]To explore nursing strategy for comprehensive treatment of children with fulminant myocarditis by multidisciplinary team(MDT),and clarify the nursing emphasis and difficulties in the treatment of fulminant myocarditis in children.[Methods]Retrospective analysis was made on three cases of fulminant myocarditis in children treated in Taihe Hospital of Shiyan City from January 2021 to January 2022.The different clinical characteristics and treatment plans were analyzed and compared,and the nursing emphasis and difficulties in comprehensive treatment of fulminant myocarditis in children were discussed.[Results]The minimum age of three children with fulminant myocarditis was 11 days old,and the remaining two children were 9-12 years old.All three children were successfully treated,in which two cases were treated with extracorporeal membrane oxygenation(ECMO)combining with mechanical ventilation(MV),including one case of neonatal explosive myocarditis.One case was treated with temporary cardiac pacing implantation.The psychological counseling and nursing of children with fulminant myocarditis and their guardians were also critical to the successful treatment and good prognosis of the disease.[Conclusions]The condition of fulminant myocarditis in children is dangerous,and it should closely observe the changes of the illness condition.The key to successful treatment is to start a comprehensive treatment plan based on life support as early as possible.The key point of nursing is to closely assist in observing the condition at the early stage,assist in maintaining and operation during advanced life support period,and avoid complications.At the same time,strengthening the psychological care of pediatric patients and guardians and health education after leaving hospital are the key and difficult points of nursing.

Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium.It is characterized by acute onset,rapid progress and high risk of death.Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm.According to China’s practical experience,the adoption of the“life support-based comprehensive treatment regimen”(with mechanical circulation support and immunomodulation therapy as the core)can significantly improve the survival rate and long-term prognosis.Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

Fulminant myocarditis induced by SARS-CoV-2 infection without severe lung involvement:insights into COvID-19 pathogenesis

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection often leads to pulmonary complications.Cardiovascular sequelae,including myocarditis and heart failure,have also been reported.Here,the study presents two fulminant myocarditis cases infected by SARS-CoV-2 exhibiting remarkable elevation of cardiac biomarkers without significant pulmonary injury,as determined by imaging examinations.Immunohistochemical staining reveals the viral antigen within cardiomyocytes,indicating that SARSCoV-2 could directly infect the myocardium.The full viral genomes from respiratory,anal,and myocardial specimens are obtained via next-generation sequencing.Phylogenetic analyses of the whole genome and spike gene indicate that viruses in the myocardium/pericardial effusion and anal swabs are closely related and cluster together yet diverge from those in the respiratory samples.In addition,unique mutations are found in the anal/myocardial strains compared to the respiratory strains,suggesting tissue-specific virus mutation and adaptation.These findings indicate genetically distinct SARS-CoV-2 variants have infiltrated and disseminated within myocardial tissues,independent of pulmonary injury,and point to different infection routes between the myocardium and respiratory tract,with myocardial infections potentially arising from intestinal infection.These findings highlight the potential for systemic SARS-CoV-2 infection and the importance of a thorough multi-organ assessment in patients for a comprehensive understanding of thepathogenesisof COVID-19.

Early curative effect of extracorporeal membrane oxygenation in the treatment of fulminant myocarditis and its influence on prognosis

Background Adult Fulminant myocarditis(FM)is the more serious form of acute myocarditis,and extracorporeal membrane oxygenation(ECMO)is an effective adjunction that helps to maintain circulation while providing adequate treatment.The blood supply of vital organs is guaranteed,which helps patients to survive the acute attack and improves the survival rate of FM.Methods In this study,50 clinical data of adult FM patients received in our hospital from July 2018 to July 2023 were collected for retrospective analysis.According to different treatment methods,they were divided into ECMO group(n=25)and non-ECMO group(n=25).After 14 days of treatment,the level of left ventricular ejection fraction(LVEF),left ventricular end-diastolic diameter(LVEDD),left ventricular end-systolic diameter(LVESD),creatine kinase isoenzymes(CK-MB),cardiac troponinⅠ(cTnⅠ)and brain natriuretic peptide(BNP),and the incidence of complications were compared between the two groups.Results Before treatment,there was no significant difference in cardiac function between the two groups(P>0.05).After 14 days of treatment,ECMO group showed greater decline than non-ECMO group in LVESD and LVEDD,and LVEF was higher than that in the non-ECMO group(P<0.05).The level of CK-MB,cTnⅠ and BNP in ECMO group were lower than those in non-ECMO(P<0.05).The overall incidence of complications was 8% in the ECMO group,which was lower than 32% in the non-ECMO group(P<0.05).Conclusions The early efficacy of ECMO treatment in adult patients with FM is considerable,which is conducive to improving the cardiac function of patients and preventing complications.

Risk factors for extracorporeal membrane oxygenation in children with fulminant myocarditis:a single-center experience

Objective Research on the clinical features of and risk factors for extracorporeal membrane oxygenation(ECMO)in pediatric fulminant myocarditis(FM)are currently limited.We aimed to investigate the clinical features and outcomes of patients with pediatric FM,and to analyze the actors associated with the need for ECMO.Methods We analyzed a retrospective cohort of patients with FM admitted to the Pediatric Department of Guangdong Provincial People's Hospital,China,between 1 January 2009 and 31 December 2021.The demographic and physiological variables were summarized and compared between patients treated with and without ECMO.Results Thirty-four patients met the criteria for FM(14 male,20 female);mean age 8.0±3.7 years,range 4 months to 15.6 years.Three patients abandoned therapy,twenty-nine patients(85.3%)survived to hospital discharge.Nine patients(26.5%)received ECMO,and eight(88.9%)of these survived.At admission,patients requiring ECMO had significantly higher levels of creatine kinase MB(CK-MB;112.1 vs 77.7 U/L,p=0.045),lower left ventricular ejection fraction(LVEF;37.0%vs 49.5%,p=0.033),and fractional shortening(16.2%vs 25.9%,p=0.012).During disease progression,the ECMO group also had significantly higher peak CK-MB(109.3 vs 60.5 U/L,p=0.041),serum B-type natriuretic peptide(35,000 vs 19,433 pg/mL,p=0.001),and troponin I(12.6 vs 6.5 ng/mL,p=0.012),and significantly lower minimum LVEF(25.0%vs 45.8%,p<0.001).Mechanical ventilation and days of mechanical ventilation were significantly associated with the need for ECMO.Patients in the ECMO group had significantly longer intensive care unit stays than patients without ECMO(15.0 vs 5.0 days,p<0.001).Conclusion Initial levels of CK-MB,LVEF,and fractional shortening are possible risk factors for ECMO in children with FM.

Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline

The features of myocardial strains from speckle-tracking echocardiography (STE) have not been well defined in fulminant myocarditis (FM) patients.In this study,changes in the left ventricular ejection fraction (LVEF) and global and layer-specific myocardial strains over time were monitored.We aimed to determine the echocardiographic patterns of FM and ascertain their significance in FM treatment.Twenty patients who were clinically diagnosed with FM and received mechanical life support were prospectively enrolled.Conventional echocardiographic measurements were obtained,and serial strain echocardiography was performed from admission to hospital discharge until LVEF recovery (> 50%).Global/regional peak systolic longitudinal strains (GLS/RLS) and layer-specific longitudinal strains were quantified,and their changes with time were monitored in 14 FM patients.All patients had severely impaired cardiac function.Steep improvement in LVEF and GLS were observed within 6 days.Layer-specific strain analysis showed that reduction at admission or recovery at discharge in the endocardium and epicardium strains were equal.In conclusion,FM patients who received mechanical circulatory supports exhibited steep improvement in ventricular function within 6 days.The patchy and diffused distribution pattern of reduced RLS and equally and severely impaired strain in the endocardium and epicardium are valuable features in the diagnosis of FM.

Clinical characteristics and mortality risk prediction model in children with acute myocarditis

Background Acute myocarditis(AMC)can cause poor outcomes or even death in children.We aimed to identify AMC risk factors and create a mortality prediction model for AMC in children at hospital admission.Methods This was a single-center retrospective cohort study of AMC children hospitalized between January 2016 and January 2020.The demographics,clinical examinations,types of AMC,and laboratory results were collected at hospital admission.In-hospital survival or death was documented.Clinical characteristics associated with death were evaluated.Results Among 67 children,51 survived,and 16 died.The most common symptom was digestive disorder(67.2%).Based on the Bayesian model averaging and Hosmer–Lemeshow test,we created a final best mortality prediction model(acute myocarditis death risk score,AMCDRS)that included ten variables(male sex,fever,congestive heart failure,left-ventricular ejection fraction<50%,pulmonary edema,ventricular tachycardia,lactic acid value>4,fulminant myocarditis,abnormal creatine kinase-MB,and hypotension).Despite differences in the characteristics of the validation cohort,the model discrimination was only marginally lower,with an AUC of 0.781(95%confidence interval=0.675–0.852)compared with the derivation cohort.Model calibration likewise indicated acceptable fit(Hosmer‒Lemeshow goodness-of-fit,P¼=0.10).Conclusions Multiple factors were associated with increased mortality in children with AMC.The prediction model AMCDRS might be used at hospital admission to accurately identify AMC in children who are at an increased risk of death.

Clinical application of extracorporeal membrane oxygenation in children with refractory cardiopulmonary failure

Background:This study aimed to discribe the experience in supporting children with refractory cardiopulmonary failure with extracorporeal membrane oxygenation(ECMO).Methods:We retrospectively reviewed 12 children with refractory cardiopulmonary failure supported with ECMO from February 2009 to August 2015 in the Pediatric Intensive Care Unit(PICU),Children's Hospital,Zhejiang University School of Medicine.Results:Seven of the 12 patients were weaned successfully from ECMO and dischaged from the hospital,with a survival rate of 58.3%(7/12).Among them,fi ve patients had acute fulminant myocarditis(AFM).Complications during ECMO included hemorrhage,hemolysis,thrombosis,acute kidney injury,and secondary hematogenous infection.During 1-24 month follow-up,the seven surviving patients recovered with normal cardiopulmonary function.Conclusion:ECMO is useful for supporting children with refractory cardiopulmonary failure,especially for treatment of AFM.