Routine performance of endomyocardial biopsy decreases the incidence of orthotopic heart transplant for myocarditis.
BACKGROUND
In critically ill children presenting with dilated cardiomyopathy (DCM), the presence of myocarditis predicts an improved chance of myocardial recovery. Noninvasive differentiation of myocarditis from other causes of DCM is difficult. However, sensitivity of endomyocardial biopsy has been questioned.


METHODS
We reviewed clinical, echocardiographic, catheterization, and pathology data from all children admitted to the intensive care unit with DCM undergoing orthotopic heart transplantation since the inception of our transplant program in 1987 and all patients with definitively diagnosed myocarditis presenting since 1996.


RESULTS
Thirty-six patients with DCM underwent orthotopic heart transplantation. Cellular infiltrate was present in 3 of 36 (8.3%) explanted specimens. Pre-transplant biopsy was performed in 81%. No explanted heart demonstrated infiltrates after a negative biopsy. One biopsy was positive with negative explant histology after transplant 6 months later. No patient with biopsy-proven myocarditis died while listed for transplantation. Eleven additional patients with myocarditis did not undergo transplant. Ten have survived and experienced complete (n = 9) or near complete (n = 1) recovery of myocardial function. One patient died shortly after presentation from fulminant myocarditis. The 10 transplant-free survivors could not be easily distinguished from our transplant cohort by clinical features at presentation.


CONCLUSIONS
The incidence of cellular infiltrate in explanted hearts was significantly lower than that previously reported. Potentially, our aggressive myocarditis diagnostic protocol was useful in therapeutic stratification as a cohort of myocarditis patients avoided transplant and experienced complete recovery of myocardial function despite being difficult to distinguish clinically from our DCM transplant cohort at presentation.
Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee 37232, USA. kevin.hill@vanderbilt.edu
Kevin D
KD
Hill
James B
JB
Atkinson
Thomas P
TP
Doyle
Debra
D
Dodd
D001706:Biopsy / Q000706:statistics & numerical data*; D002675:Child, Preschool; D003937:Diagnosis, Differential; D004699:Endocardium / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D016027:Heart Transplantation / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D009205:Myocarditis / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery; D009206:Myocardium / Q000473:pathology*; D011379:Prognosis; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology