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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

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Front. Med.    2020, Vol. 14 Issue (3) : 284-292    https://doi.org/10.1007/s11684-019-0713-9
RESEARCH ARTICLE
Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline
Houjuan Zuo1,2, Rui Li1,2, Fei Ma1,2, Jiangang Jiang1,2, Kun Miao1,2, Haojie Li3, Eike Nagel4, Marijana Tadic5, Hong Wang1,2(), Dao Wen Wang1,2()
1. Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
2. Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiologic Disorders, Wuhan 430030, China
3. Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
4. Institute for Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt/Main, Frankfurt, Germany
5. Department of Internal Medicine and Cardiology, Charité–Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
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Abstract

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.
Keywords fulminant myocarditis      acute myocarditis      2D speckle tracking echocardiography      left ventricular function      global longitudinal strain     
Corresponding Author(s): Hong Wang,Dao Wen Wang   
Just Accepted Date: 10 October 2019   Online First Date: 19 December 2019    Issue Date: 08 June 2020
 Cite this article:   
Houjuan Zuo,Rui Li,Fei Ma, et al. Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline[J]. Front. Med., 2020, 14(3): 284-292.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-019-0713-9
https://academic.hep.com.cn/fmd/EN/Y2020/V14/I3/284
Fig.1  CMR images of two patients with FM showed edema in the left ventricle. Short-axis view of cardiac MRI phase-sensitive inversion recovery sequence showing LGE in the wall. (A) A 19-year-old male and (B) another 17-year-old male with diffuse myocardial hyper-intense signal at T2WI (signal intensity ratio between myocardium and skeletal muscle= 3.5; arrows) and diffuse LGE pattern (arrows).
Male, n (%) 9 (45)
Age (year) 34±18
Height (cm) 164±5
Weight (kg) 63.5±9.2
Clinical presentation
Flu-like illness 20 (100%)
Fever 18 (90%)
Chest tightness 19 (95%)
Vomit 8 (40%)
Diarrhea 5 (25%)
Physical examinations
Systolic blood pressure (mmHg) 91±11
Diastolic blood pressure (mmHg) 59±10
Heart rate (bpm) 100±23
Temperature at admission (°C) 36.6±0.3
Laboratory findings
Leucocytes, 109/L 9.6±3.6
ESR (mm/h) 17.1±19.9
C-reactive protein (mg/L) 65.2±86.5
Peak troponin-T (pg/mL) 28 864.7±17 372.9
NT-proBNP (pg/mL) 17 019.2±16 796.4
ALT (U/L) 224.4±652.7
AST (U/L) 354.9±643.6
Creatinine (mmol/L) 83.7±43.7
Lactic acid (mmol/L) 2.8±1.1
Glucose (mg/dL) 8.4±1.6
ECG at admission
ST segment elevation, n (%) 8 (40)
Episodes of complete AV block during myocarditis, n (%) 5 (25)
Non-sustain ventricular tachycardia, n (%) 6 (30)
Coronary angiography performed, n (%) 7 (35)
In-hospital day (day) 12±4
Treatments in-hospital
Methylprednisolone, n (%) 20 (100)
Gamma globulin, n (%) 20 (100)
CRRT, n (%) 18 (90)
IABP, n (%) 20 (100)
ECMO, n (%) 5 (25)
Tab.1  Baseline clinical characteristics of patients with fulminant myocarditis ( total= 20)
Parameters Admission (n = 20) Hospital discharge (n = 20) P
IVS diastolic (cm) 1.07±0.19 1.05±0.18 0.336
IVS systolic (cm) 1.33±0.18 1.37±0.16 0.168
LVPW diastolic (cm) 1.03±0.21 1.01±0.16 0.345
LVPW systolic (cm) 1.27±0.19 1.34±0.13 0.057
LVEDD (cm) 4.53±0.47 4.5±0.52 0.316
LVESD (cm) 3.49±0.53 3.22±0.53 0.016
LVEDV (mL) 98.26±23.67 100.36±22.50 0.319
LVESV (mL) 63.57±19.71 47.26±14.92 <0.001
LA diameter (cm) 3.03±0.51 2.91±0.48 0.205
EF (%) 30±12 59±7 <0.001
FS (%) 15±6 32±6 <0.001
E 76.92±22.45 76.14±20.21 0.45
A 54.81±22.62 58.25±21.31 0.328
E/A 1.61±0.69 1.28±0.55 0.06
E/E' 18.74±11.6 11.22±3.46 0.008
Tab.2  Conventional echocardiographic parameters measurements
Parameters Admission (n = 14) Hospital discharge (n = 14) P
GLS (%) −8.45±3.83 −16.95±1.85 <0.001
Apical PSLS (%) −8.14±5.44 −19.21±3.98 <0.001
Mid PSLS (%) −8.48±3.70 −16.00±2.51 <0.001
Basal PSLS (%) −7.22±3.82 −13.93±4.40 <0.001
Mid and basal PSLS (%) −7.85±3.36 −14.97±3.15 <0.001
Tab.3  Strain analysis of FM between admission and hospital discharge
Fig.2  (A) Comparison of regional strain upon admission and hospital discharge. (B) Representative images of the regional strain distribution presented as “bull’s-eye” displays, showing strain changes in FM patient on day 1, day 5, and day10 of hospitalization. Fourteen of the twenty patients were enrolled for strain analysis, and six patients were excluded for the unanalyzable strain data. *P<0.05, ** P<0.001 compared with the values taken on admission.
Fig.3  Changes in EF and GLS with time at an interval of approximately 1 day were displayed in all FM patients. EF and GLS varied with time in FM patients. Fourteen of the twenty patients were enrolled for strain analysis, and six patients were excluded for the unanalyzable strain data. *P<0.05, ** P<0.001 compared with the values taken 1 day after admission.
Fig.4  (A) Quantification of the layer-specific strains upon admission and hospital discharge. No difference was observed between the epicardium and endocardium. *P<0.05 compared with the values obtained upon admission. (B) Representative bull’s-eye display of the layer-specific strains upon admission and hospital discharge. Endo, endocardium; Epi, epicardium.
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