title: Myocarditis as a precipitating factor for heart failure: evaluation and 1-year follow-up using cardiovascular magnetic resonance and endomyocardial biopsy.
abstract: OBJECTIVE
  The aim of this study was to evaluate myocarditis as a precipitating factor for heart failure using cardiovascular magnetic resonance (CMR) and endomyocardial biopsy.
  
  
  RESULTS
  Eighty-five patients with suspected myocarditis and 20 controls were evaluated. Seventy-one patients with positive CMR were referred for endomyocardial biopsy and re-evaluation after 1 year. Cardiovascular magnetic resonance was performed using STIR T2-weighted (T2W), early T1-weighted (EGE), and late gadolinium-enhanced (LGE) images. Immunohistological and polymerase chain reaction (PCR) analysis of myocardial specimens was employed. In patients with myocarditis, T2 and EGE were increased compared with controls (2.6 ± 0.9 vs. 1.57 ± 0.13, P < 0.001 and 7.9 ± 5.5 vs. 3.59 ± 0.08, P < 0.001, respectively). Late gadolinium enhancement was found in all myocarditis patients. Endomyocardial biopsy performed in 50 of 71 patients with positive CMR showed positive immunohistology in 48% and presence of infectious genomes in 80% (mainly Chlamydia, Herpes, and Parvovirus B19). Left ventricular ejection fraction (LVEF) was significantly decreased compared with controls (47.7 ± 19.2 vs. 64 ± 0.2, P < 0.001). After 1 year, CMR showed normalization of T2 and EGE, and decreased LGE. Left ventricular ejection fraction increased in 36.5% of patients, remained stable in 56.5% and decreased in 7% of patients, in whom biopsy showed persistence of the initial infective agents. A negative correlation was identified between EGE, LGE, and LVEF. Patients with positive biopsies had lower LVEFs.
  
  
  CONCLUSIONS
  In a Greek population with myocarditis, Chlamydia with viruses was a common finding. Cardiovascular magnetic resonance and PCR proved useful for the detection of myocarditis; EGE and LGE had the best correlation for the development of heart failure. Persistence of the initially detected infective agents was identified in patients who deteriorated further.
authors.affiliation: Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61 P.Faliro, Athens, Greece. soma13@otenet.gr
authors.forename: Sophie
authors.initials: S
authors.lastname: Mavrogeni
authors.forename: Costas
authors.initials: C
authors.lastname: Spargias
authors.forename: Costas
authors.initials: C
authors.lastname: Bratis
authors.forename: Genovefa
authors.initials: G
authors.lastname: Kolovou
authors.forename: Vyron
authors.initials: V
authors.lastname: Markussis
authors.forename: Evangelia
authors.initials: E
authors.lastname: Papadopoulou
authors.forename: Pantelis
authors.initials: P
authors.lastname: Constadoulakis
authors.forename: Miltiadis
authors.initials: M
authors.lastname: Papadimitropoulos
authors.forename: Marouso
authors.initials: M
authors.lastname: Douskou
authors.forename: Gregory
authors.initials: G
authors.lastname: Pavlides
authors.forename: Denis
authors.initials: D
authors.lastname: Cokkinos
mesh_terms: D000328:Adult; D001707:Biopsy, Needle; D005500:Follow-Up Studies; D005682:Gadolinium; D006333:Heart Failure / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D009205:Myocarditis / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology*; D009206:Myocardium / Q000473:pathology*; D015985:Precipitating Factors; D019275:Radiopharmaceuticals
chemical_list: D019275:Radiopharmaceuticals; D005682:Gadolinium