title: When should we consider the diagnosis of giant cell myocarditis? Revisiting "classic" echocardiographic and clinical features of this rare pathology.
abstract: OBJECTIVE
  Giant cell myocarditis is a rare and often fatal disorder. According to the American Heart Association, the American College of Cardiology Foundation, and the European Society of Cardiology scientific statements, an endomyocardial biopsy should be done to exclude giant cell myocarditis in unexplained new-onset heart failure of 2 weeks to 3 months duration associated with dilated left ventricle and new ventricular arrhythmias, or Mobitz type II second-degree, or third-degree atrioventricular heart block.
  
  
  METHODS
  Two hundred thirty-five heart transplants were performed since May 1993 at the Institut universitaire de cardiologie et de pneumologie de Quebec, Canada. Giant cell myocarditis was found in the explanted hearts of 5 patients. The preoperative diagnosis of giant cell myocarditis was done by endomyocardial biopsy or at the installation of a left ventricular-assisted device. Patients had symptoms of progressive heart failure of subacute onset. Patients consulted at a mean 32 days after the onset of symptoms. Two patients neither had ventricular arrhythmia nor heart block. Two patients had ventricular arrhythmias and heart block; the other patient had symptomatic heart block. All patients had at least 2 echocardiographies. Two patients had an increase in left ventricular size, enough to reach the criteria of left ventricular dilatation according to the American Society of Echocardiography. During this time, left ventricular ejection fraction showed a rapid decline (mean 37% to 16%).
  
  
  CONCLUSIONS
  Ventricular arrhythmia, heart block, and left ventricular dilatation initially can be absent in many patients having giant cell myocarditis with symptoms of progressive heart failure. Endo-myocardial biopsy should be quickly considered in patients with a rapid and dramatic decline of left ventricular ejection fraction, even in the absence of classic clinical and echocardiographic features of giant cell myocarditis to rapidly obtain the diagnosis of this rare but lethal disease.
authors.affiliation: Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec, Canada.
authors.forename: Maxime
authors.initials: M
authors.lastname: Berthelot-Richer
authors.forename: Kim
authors.initials: K
authors.lastname: O'Connor
authors.forename: Mathieu
authors.initials: M
authors.lastname: Bernier
authors.forename: Sylvain
authors.initials: S
authors.lastname: Trahan
authors.forename: Christian
authors.initials: C
authors.lastname: Couture
authors.forename: Michelle
authors.initials: M
authors.lastname: Dubois
authors.forename: Mario
authors.initials: M
authors.lastname: Sénéchal
mesh_terms: D000328:Adult; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D001706:Biopsy; D004452:Echocardiography; D017809:Fatal Outcome; D005260:Female; D015726:Giant Cells / Q000000981:diagnostic imaging / Q000473:pathology; D006333:Heart Failure / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D016027:Heart Transplantation; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D009206:Myocardium / Q000473:pathology*; D011237:Predictive Value of Tests; D011792:Quebec; D013318:Stroke Volume; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D016277:Ventricular Function, Left