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. 2020 Mar 10;75(9):1046-1057.
doi: 10.1016/j.jacc.2020.01.036.

Ventricular Arrhythmias in Myocarditis: Characterization and Relationships With Myocardial Inflammation

Giovanni Peretto  1 , Simone Sala  2 , Stefania Rizzo  3 , Anna Palmisano  4 , Antonio Esposito  4 , Francesco De Cobelli  4 , Corrado Campochiaro  5 , Giacomo De Luca  5 , Luca Foppoli  6 , Lorenzo Dagna  5 , Gaetano Thiene  3 , Cristina Basso  3 , Paolo Della Bella  2
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Free article

Ventricular Arrhythmias in Myocarditis: Characterization and Relationships With Myocardial Inflammation

Giovanni Peretto et al. J Am Coll Cardiol. .
Free article

Abstract

Background: Ventricular arrhythmias (VAs) have never been systematically investigated in patients with myocarditis at different stages.

Objectives: The purpose of this study was to compare baseline and follow-up characteristics of VAs in patients with active myocarditis (AM) versus previous myocarditis (PM).

Methods: A total of 185 consecutive patients (69% males, age 44 ± 15 years, left ventricular ejection fraction 49 ± 14%) with myocarditis and VA at index hospitalization, including ventricular fibrillation, ventricular tachycardia (VT), nonsustained ventricular tachycardia (NSVT), and Lown's grade ≥2 premature ventricular complexes, were enrolled. AM and PM groups were defined based on endomyocardial biopsy and cardiac magnetic resonance findings. A subset of patients (n = 46, 25%) also underwent electroanatomic mapping and VA transcatheter ablation.

Results: At presentation, AM patients (n = 123, 66%) more commonly had ventricular fibrillation (8 cases vs. 0 cases; p = 0.053), and both irregular (61% vs. 11%; p < 0.001) and polymorphic VA (NSVT and VT: 19% vs. 2%; p = 0.002; premature ventricular complexes: 63% vs. 16%; p < 0.001). Only in PM patients with NSVT or VT, the dominant morphology (right-bundle branch block with superior axis) was 100% predictive of abnormal LV inferoposterior substrate at both cardiac magnetic resonance and electroanatomic mapping. At 27 ± 7 months prospective follow-up, 55 patients (30%) experienced malignant VA (AM vs. PM, p = 0.385). Although a prevalence of polymorphic and irregular VA was confirmed in AM patients with persistent inflammation in follow-up (58%), a predominance of monomorphic and regular VA was found in AM patients after myocarditis healing (42%), as well as in PM patients (all p < 0.001).

Conclusions: In myocarditis patients, polymorphic and irregular VA are more common during the active inflammatory phase, whereas monomorphic and regular VA are associated with healed myocarditis.

Keywords: cardiac magnetic resonance; electroanatomic mapping; endomyocardial biopsy; myocarditis; ventricular arrhythmias.

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