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CLINICAL STUDIES: MYOCARDITIS

Echocardiographic findings in fulminant and acute myocarditis

G. Michael Felker, MD^*, John P. Boehmer, MD, FACC, Ralph H. Hruban, MD, Grover M. Hutchins, MD, Edward K. Kasper, MD, FACC^*, Kenneth L. Baughman, MD, FACC^* and Joshua M. Hare, MD, FACC^*

^* Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
Division of Cardiology, Hershey Medical Center, Hershey, Pennsylvania, USA

Manuscript received June 24, 1999; revised manuscript received January 21, 2000, accepted March 6, 2000.

Reprint requests and correspondence: Dr. Joshua M. Hare, Division of Cardiology, the Johns Hopkins Hospital, Carnegie 568, 600 North Wolfe Street, Baltimore, Maryland 21287
jhare{at}mail.jhmi.edu

OBJECTIVES

We sought to use echocardiography to assess the presentation and potential for recovery of left ventricular (LV) function of patients with fulminant myocarditis compared with those with acute myocarditis.

BACKGROUND

The clinical course of patients with myocarditis remains poorly defined. We have previously proposed a classification that provides prognostic information in myocarditis patients. Fulminant myocarditis causes a distinct onset of illness and severe hemodynamic compromise, whereas acute myocarditis has an indistinct presentation, less severe hemodynamic compromise and a greater likelihood of progression to dilated cardiomyopathy.

METHODS

Echocardiography was performed at presentation and at six months to test the hypothesis that fulminant (n = 11) or acute (n = 43) myocarditis could be distinguished morphologically.

RESULTS

Patients with both fulminant (fractional shortening 19 ± 4%) and acute myocarditis (17 ± 7%) had LV systolic dysfunction. Patients with fulminant myocarditis had near normal LV diastolic dimensions (5.3 ± 0.9 cm) but increased septal thickness (1.2 ± 0.2 cm) at presentation, while those with acute myocarditis had increased diastolic dimensions (6.1 ± 0.8 cm, p < 0.01 vs. fulminant) but normal septal thickness (1.0 ± 0.1 cm, p = 0.01 vs. fulminant). At six months, patients with fulminant myocarditis had dramatic improvement in fractional shortening (30 ± 8%) compared with no improvement in patients with acute myocarditis (19 ± 7%, p < 0.01 for interaction between time and type of myocarditis).

CONCLUSIONS

Fulminant myocarditis is distinguishable from acute myocarditis by echocardiography. Patients with fulminant myocarditis exhibit a substantial improvement in ventricular function at six months compared with those with acute myocarditis. Echocardiography has value in classifying patients with myocarditis and may provide prognostic information.

Abbreviations and Acronyms   DCM = dilated cardiomyopathy   LV = left ventricle or ventricular   LVEDD = left ventricular diastolic dimension   %FS = percentage fractional shortening

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