Myocarditis

Young Soldier With A Failing Heart Manju Goyal, M.D. Walter Reed Army Medical Center April 2008

Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Case ,[object Object],[object Object],Young patient in SHOCK with concerning cardiac exam and EKG

Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],New onset of Dilated Cardiomyopathy (DCM)

Dilated Cardiomyopathy www.uptodate.com

Review of 1230 Patients with DCM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],NEJM 2000

Importance of Etiology NEJM 2000

Additional Tests ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],What’s the differential? Any further tests?

Review of 1230 Patients with DCM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],NEJM 2000 Endomyocardial Biopsy

Biopsy Results Dr. Brendan Graham Dept. of Pathology

Case of Viral Myocarditis ,[object Object],[object Object],[object Object],[object Object],[object Object]

Objectives: Myocarditis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Myocarditis ,[object Object],[object Object]

Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1. Circulation 1976 2. Ann Intern Med 2004

Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Pathophysiology of Viral Myocarditis Braunwald 2007

Viral Phase ,[object Object],[object Object],[object Object],[object Object],Braunwald 2007

Immune Response Braunwald 2007 Autoimmune response : auto-antibodies to myosin and other cardiac proteins Overexpression of cytokines (IL-2, INF- γ , TNF- α )

Clinical Presentation Acute Fulminant Chronic ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnosis: Cardiac MRI ,[object Object],[object Object],[object Object],[object Object],WITH Contrast WITHOUT Contrast Eur Heart J 1994 LV RV RV LV

Diagnosis: Coronary Angiography ,[object Object],[object Object],[object Object]

Diagnosis: Endomyocardial Biopsy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

When to consider biopsy? Mayo Clin Proc 2001

Treatment Dr. Barnett Gibbs Dept. of Cardiology

Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]

Intra-aortic balloon pump ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Intra-aortic balloon pump ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Ventricular-assist device ,[object Object],[object Object],[object Object]

* *Centrifugal pump vs. corkscrew

Ventricular-assist device ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Ventricular-assist device ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],CID. 2005;40:1108.

Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Medical therapy ,[object Object],[object Object],[object Object],[object Object]

Medical therapy ,[object Object],[object Object],[object Object],[object Object],Am Heart J. 1990;120:1377.

Medical therapy ,[object Object],Circulation. 1991;83:2021..

Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Immunosuppressive Therapies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Int Heart J. 2005;46:113.

Immunosuppressive Therapies Int Heart J. 2005;46:113.

Immunosuppressive Therapies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Int Heart J. 2005;46:113. NEJM. 2000;343:1388.

Prognosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],NEJM. 2000;342:1077.

Prognosis ,[object Object],[object Object],NEJM. 2000;342:1077.

Prognosis NEJM. 2000;342:1077.

Prognosis ,[object Object],[object Object],[object Object],[object Object]

SUMMARY ,[object Object],[object Object],[object Object],[object Object]

Back to the case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Conclusion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Biopsy ,[object Object],[object Object],[object Object],[object Object],[object Object]

Myocarditis

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Myocarditis