title: Long-term follow-up of biopsy-proven viral myocarditis: predictors of mortality and incomplete recovery.
abstract: OBJECTIVE
  This study sought to evaluate the long-term mortality in patients with viral myocarditis, and to establish the prognostic value of various clinical, functional, and cardiovascular magnetic resonance (CMR) parameters.
  
  
  BACKGROUND
  Long-term mortality of viral myocarditis, as well as potential risk factors for poor clinical outcome, are widely unknown.
  
  
  METHODS
  A total of 222 consecutive patients with biopsy-proven viral myocarditis and CMR were enrolled. A total of 203 patients were available for clinical follow-up, and 77 patients underwent additional follow-up CMR. The median follow-up was 4.7 years. Primary endpoints were all-cause mortality and cardiac mortality.
  
  
  RESULTS
  We found a relevant long-term mortality in myocarditis patients (19.2% all cause, 15% cardiac, and 9.9% sudden cardiac death [SCD]). The presence of late gadolinium enhancement (LGE) yields a hazard ratio of 8.4 for all-cause mortality and 12.8 for cardiac mortality, independent of clinical symptoms. This is superior to parameters like left ventricular (LV) ejection fraction, LV end-diastolic volume, or New York Heart Association (NYHA) functional class, yielding hazard ratios between 1.0 and 3.2 for all-cause mortality and between 1.0 and 2.2 for cardiac mortality. No patient without LGE experienced SCD, even if the LV was enlarged and impaired. When focusing on the subgroup undergoing follow-up CMR, we found an initial NYHA functional class >I as the best independent predictor for incomplete recovery (p = 0.03).
  
  
  CONCLUSIONS
  Among our population with a wide range of clinical symptoms, biopsy-proven viral myocarditis is associated with a long-term mortality of up to 19.2% in 4.7 years. In addition, the presence of LGE is the best independent predictor of all-cause mortality and of cardiac mortality. Furthermore, initial presentation with heart failure may be a good predictor of incomplete long-term recovery.
authors.affiliation: Department of Cardiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, Stuttgart, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Grün
authors.forename: Julia
authors.initials: J
authors.lastname: Schumm
authors.forename: Simon
authors.initials: S
authors.lastname: Greulich
authors.forename: Anja
authors.initials: A
authors.lastname: Wagner
authors.forename: Steffen
authors.initials: S
authors.lastname: Schneider
authors.forename: Oliver
authors.initials: O
authors.lastname: Bruder
authors.forename: Eva-Maria
authors.initials: EM
authors.lastname: Kispert
authors.forename: Stephan
authors.initials: S
authors.lastname: Hill
authors.forename: Peter
authors.initials: P
authors.lastname: Ong
authors.forename: Karin
authors.initials: K
authors.lastname: Klingel
authors.forename: Reinhardt
authors.initials: R
authors.lastname: Kandolf
authors.forename: Udo
authors.initials: U
authors.lastname: Sechtem
authors.forename: Heiko
authors.initials: H
authors.lastname: Mahrholdt
mesh_terms: D000328:Adult; D001706:Biopsy / Q000379:methods*; D053821:Cardiovascular Infections / Q000401:mortality / Q000473:pathology* / Q000821:virology; D002423:Cause of Death / Q000639:trends; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000401:mortality / Q000473:pathology* / Q000821:virology; D009206:Myocardium / Q000473:pathology*; D011379:Prognosis; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014777:Virus Diseases / Q000401:mortality / Q000473:pathology* / Q000821:virology