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Dr. Juerg Schwitter,
Prof. Christina Basso, pathologist, from Padua opened the session by providing newest insights into the gold standard for the diagnosis of myocarditis. But first, she stressed the fact that myocarditis is the etiology for 1 out of 10 sudden cardiac deaths in the young. Given the broad variety of possible agents causing myocarditis, only endomyocardial biopsy (EMB) is able to yield the diagnosis. Prof. Basso then elegantly illustrated that the Dallas criteria (defined in 1987) underestimate the prevalence of myocarditis, and the new gold standard must add molecular analyses and immuno-histochemistry to the histological criteria. With these tools, viruses are detectable in up to 42% in children with myocarditis and of these, adeno- and influenza-viruses can account for up to 60%.
Prof. Fausto Pinto, Lisbon, then presented echocardigraphic data of myocarditis, underlining that often, subtle changes in function and sometimes thickened myocardial walls can give a hint for the presence of myocarditis. He then also pointed out that the sensitivity to diagnose EMB ranges in the literature from 9-70%. Here sampling errors might play a role.
Dr. Heiko Marholdt from Stuttgart then demonstrated convincing cases investigated by cardiac Magnetic Resonance (CMR), where inflammatory foci can be detected with high sensitivities and specificities of 76% and 91%, respectively (meta-analysis) versus EMB. Also, T2-weighted imaging by CMR for oedema detection may add information in certain cases.
Prof. Schultheiss from Berlin underlined then the importance of virus persistence predicting a bad outcome. Also, expression of adhesion molecules correlates with virus persistence. With virus persistence, there might be an option for interferon-beta treatment in the future, while in virus-negative cases, immunosuppression might be indicated.
The session discussed in depth the role of adequate EMB work-up for reaching the diagnosis and characterising the status of disease, e.g. in viral infections. Echocardiography can be a very helpful tool in suspected cases. CMR offers the unique possibility to directly visualise inflammatory foci to monitor myocarditis activity, control therapeutic effects, and guide biopsies in cases with rapid progression.
Myocarditis: update on imaging and contemporary management
This congress report accompanies a presentation given at the ESC Congress 2008. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.
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