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Highlights • GC–MS, RPLC-MS and HILIC-MS metabolomic assessed the efficacy of SFI on AVMC. • Computational systems analysis identified SFI-targeted metabolic pathways. • RT-PCR analysis validated the key enzymes in the SFI-targeted pathways. Abstract Acute viral myocarditis (AVMC) is typically caused by cardiotropic viral infection. There is a paucity of specific treatment options available with proven efficacy. Chinese patented pharmaceutical product Shenfu injection (SFI) has potent efficacy on treating AVMC in clinical practice. However, the molecular mechanism is still unknown. We employed cross-platform metabolomics combined with computational systems analysis, based on reversed-phase liquid chromatography–mass spectrometry (RPLC-MS), hydrophilic interaction liquid chromatography–mass spectrometry (HILIC-MS) and gas chromatography-mass spectrometry (GC–MS), to deciphering the targeted metabolic pathways of SFI against AVMC induced by coxsackievirus B3 (CVB3). Quantitative real-time PCR (qRT-PCR) technique was further applied to determining the expressions of the key genes associated with the SFI-targeted metabolic pathways. We have identified 48 significantly changed metabolites related to CVB3-induced AVMC, and SFI can significantly regulate the abnormalities of 33 metabolites and 9 relevant enzymes. Combined metabolic pathway enrichment and topology analyses revealed that the mechanisms of SFI against CVB3-induced AVMC may be attributed to modulating the disordered homeostasis of sphingolipid metabolism, glycerophospholipid metabolism, arachidonic acid metabolism, tryptophan metabolism, and TCA cycle. It provides new experimental information on the pathogenesis of AVMC, unravels the potential targeted metabolic pathways of SFI against AVMC on the whole metabolic network and highlights the importance of metabolomics combined with computational systems analysis as a potential tool for deciphering drug-targeted metabolic pathways. [ABSTRACT FROM AUTHOR]

Background: Eosinophilic myocarditis (EM) is an acute life-threatening inflammatory disease of the heart. Neither large case series nor clinical trials on this specific myocarditis have been reported.Objectives: Based on a systematic revision of all published histologically proven cases, this study aimed to describe the clinical presentation, treatment, and outcome of EM.Methods: The study screened 443 manuscripts in MEDLINE and EMBASE on cases of EM published until June 2017. The authors identified 264 patients and included in the main analysis 179 patients admitted to hospital with histologically proven EM.Results: Median age was 41 years (interquartile range: 27 to 53 years) with similar prevalence in both sexes; pediatric cases (≤16 years of age) accounted for 10.1%. The main symptom at presentation was dyspnea (59.4%), with peripheral eosinophilia observed in 75.9%. Median left ventricular ejection fraction at presentation was 35% (interquartile range: 25% to 50%). The disorders most frequently associated with EM were hypersensitivity and eosinophilic granulomatosis with polyangiitis, which accounted for 34.1% and 12.8% of cases, respectively, whereas idiopathic or undefined forms accounted for 35.7% of cases. Steroids were administered in 77.7% of patients. A temporary mechanical circulatory support (n = 30) was instituted in 16.8% of patients. In-hospital death was 22.3% (n = 40), with the highest occurrence in the hypersensitivity form (36.1%; p = 0.026).Conclusions: EM has a poor prognosis during the acute phase, despite a publication bias that could have led to an overestimation of mortality. Associated conditions are identified in approximately 65% of cases. Specific trials and multicenter registries are needed to provide evidence-based treatments to improve in-hospital outcome. [ABSTRACT FROM AUTHOR]

Myocarditis is a major cause of heart disease in young patients and a common precursor of heart failure due to dilated cardiomyopathy. Some auto-immune and/or auto-inflammatory diseases may be accompanied by myocarditis, such as sarcoidosis, Behçet's disease, eosinophilic granulomatosis with polyangiitis, myositis, and systemic lupus erythematosus. However, data concerning myocarditis in such auto-immune and/or auto-inflammatory diseases are sparse. New therapeutic strategies should better target the modulation of the immune system, depending on the phase of the disease and the type of underlying auto-immune and/or auto-inflammatory disease. [ABSTRACT FROM AUTHOR]

Background Clozapine is the cornerstone of therapy for refractory schizophrenia; however, the potential for cardiotoxicity is an important limitation in its use. In the current analysis we sought to evaluate the long term cardiac outcomes of clozapine therapy. Methods All-cause mortality, incidence of sudden death and time to myocarditis were assessed in a cohort of patients maintained on clozapine between January 2009 and December 2015. All patients had regular electrocardiograms, complete blood count, clozapine levels and echocardiography as part of a formal protocol. Results A total of 503 patients with treatment-resistant schizophrenia were maintained on clozapine during the study period of which 93 patients (18%) discontinued therapy with 29 (6%) deaths. The incidence of sudden death and myocarditis were 2% (n = 10) and 3% (n = 14) respectively. Amongst patients with sudden death, 7 out of 10 (70%) were documented to have used illicit drugs prior to death, with a tendency to weight gain also noted. The mean time to myocarditis post clozapine commencement was 15 ± 7 days. The reduction in left ventricular ejection fraction in those with myocarditis was 11 ± 2%. Conclusion Myocarditis and sudden cardiac death are uncommon but clinically important complications in a cohort of patients followed while maintained on clozapine undergoing regular cardiac assessment. Further studies are required to document the role of preventive measures for left ventricular dysfunction and sudden cardiac death in this population. [ABSTRACT FROM AUTHOR]

Metformin is a widely used anti-diabetic drug and increasing evidence suggests that metformin have profound cardioprotective effects under both diabetic and non-diabetic situations. The protective benefits of metformin have been proved in diabetic patients with cardiovascular complications and in experimental animals with myocardial infarction and cardiac hypertrophy. In the present study, we found that treatment with metformin inhibited the cardiac expression of pro-inflammatory cytokines including tumor necrosis factor alpha (TNF-α), interleukin 1 beta (IL-1β) and interleukin 6 (IL-6) in endotoxin-challenged mice. Treatment with metformin also alleviated the histological abnormalities in the heart, suppressed the upregulation of myeloperoxidase (MPO), decreased the elevation of creatinine kinase-myocardial band (CK-MB) and brain natriuretic peptide (BNP). Treatment with metformin promoted the phosphorylation of the catalytic α subunit of adenosine 5′-monophosphate-activated protein kinase (AMPKα), co-administration of AMPK inhibitor suppressed the stimulatory effects of metformin on AMPKα phosphorylation. Meanwhile, the suppressive effects of metformin on MPO, TNF-α, CK-MB and BNP were reversed by the AMPK inhibitor. On the contrary, administration of AMPK activator mimicked the effects of metformin on AMPKα phosphorylation, MPO upregulation, CK-MB release and BNP elevation. These evidence suggested that metformin might provide beneficial effects in endotoxin-induced acute myocarditis via activating AMPK-dependent anti-inflammatory mechanism. [ABSTRACT FROM AUTHOR]

Oxymatrine is the primary pharmacological component of Sophora flavescens Ait . In the present study, we investigated the protective effect of oxymatrine against Coxsackievirus B3-induced myocarditis in mice. Coxsackievirus B3-infected HeLa cells were treated with oxymatrine and the viral titer, as well as the degree of cellular proliferation were determined. Additionally, BALB/c mice were infected with Coxsackievirus B3 and received differing concentrations of oxymatrine. On days 5 and 12 following treatment, mice were sacrificed, and serum lactate dehydrogenase, creatine kinase-MB isozyme, and tumor necrosis factor-α levels were quantified. The heart index and degree of myocardial tissue inflammation were also assessed. On day 5, the Coxsackievirus B3 TCID 50 values of the heart tissue, and the expression of NTR, IFN-γ, and TNF-α genes in the myocardial tissue were measured. Our results showed that oxymatrine exhibits potent antiviral effects on Coxsackievirus B3 as 50% inhibition was achieved at a concentration as low as 0.238 mg/mL. Oxymatrine markedly reduced the viral titer and inhibited cardiac myocyte pathology exhibited in viral myocarditis. Furthermore, oxymatrine treatment reduced the expression of Coxsackievirus B3 NTR and mouse TNF-α genes compared to the controls. Therefore, our findings indicate that oxymatrine is a promising potent antiviral agent against Coxsackievirus B3-induced myocarditis. [ABSTRACT FROM AUTHOR]

Viral myocarditis is a common clinical cardiovascular disease mainly induced by coxsackievirus B3 (CVB3) with no effective therapeutic measures. Induction of efficient mucosal immune responses is very critical against CVB3-induced myocarditis. FimH is an Escherichia coli ( E. coli )-derived protein, which possesses an M cell-targeting property and functions as a TLR4 agonist. In this study, we introduced the recombinant FimH protein, into our previously developed CVB3 mucosal vaccine chitosan (CS)-pVP1, aiming to provoke more efficient mucosal immune responses and immunoprotection against CVB3-induced myocarditis. Compared with the CS-pVP1 vaccine, immunization with FimH-CS-pVP1 remarkably increased the levels and neutralizing titers of CVB3-specific protective secretory IgA (sIgA), enhanced the frequency of CVB3-specific IgA-producing B cells and amplified mucosal T-cell immune responses in mesenteric lymph nodes (MLNs), although failing to significantly amplify CVB3-specific systemic immune responses. Consistently, FimH-CS-pVP1 group showed the enhanced immunoprotection against CVB3-induced myocarditis, evidenced by the indices of limited myocardial injury, reduced viral loads and enhanced survival rate. Further study showed that this enhanced immunoprotection was not only ascribed to its M cell-targeting property, which led to the enhanced mucosal antigen VP1 expression, but also associated with the mucosal adjuvant effect of FimH, which facilitated the formation of germinal centers (GCs), production of IgA-inducing factors and maturation of antigen-presenting cells (APCs). Taken together, here we developed a bi-functional mucosal vaccine FimH-CS-pVP1, which simultaneously possessed the M cell-targeting property and mucosal adjuvant ability, and we showed that FimH-CS-pVP1 could efficiently induce the higher levels of CVB3-specific protective mucosal immune responses and provide better prophylactic effects against CVB3-induced myocarditis than CS-pVP1. [ABSTRACT FROM AUTHOR]

Background and aims Myocarditis is inflammation in the heart; its pathogenesis is to be further investigated. Activities of micro RNAs (miR) are associated with immune inflammation. This study tests a hypothesis that miR-98 is involved in the development of myocarditis. Methods BALB/c mice were immunized with cardiac α-myosin heavy chain peptides (MyHC-α) to induce myocarditis. The effects of miR-98 on regulation of interleukin (IL)-10 were assessed by real time RT-PCR. Results Mice immunized with MyHC-α showed myocarditis and lower frequency of IL-10 + B cells (B10 cell) in the hearts. Expression of miR-98 was higher, IL-10 was lower, in B cells isolated from the mouse hearts with myocarditis, which was negatively correlated with each other. Exposure to tumor necrosis factor-α up regulated miR-98 expression in B cells. Over-expression of miR-98 suppressed IL-10 expression in B cells. Blocking miR-98 or adoptively transplanting B10 cells attenuated experimental myocarditis. Conclusions miR-98 suppresses IL-10 expression in B cells in the heart, which plays an important role in myocarditis. MiR-98 may be a therapeutic target in the treatment of myocarditis. [ABSTRACT FROM AUTHOR]

Background Coxsackievirus (CVB3) infection is the most common cause of viral myocarditis (VMC) characterized by viral infection and myocardial inflammation. ADAR1, the interferon (IFN)-inducible adenosine deaminase acting on RNA, has been reported to be functional in various viruses. Recent studies have demonstrated that ADAR1 holds an antiviral role or promotes viral replication depending on virus type. Objectives This study aims to investigate whether or not ADAR1 affects CVB3-induced VMC. Methods We generated an acute VMC mouse model by CVB3 infection. ADAR1 expression was manipulated by in vivo polyethyleneimine-mediated ADAR1 up/down-regulation plasmid delivery. Results Our study indicated that ADAR1 was up-regulated after CVB3 infection. ADAR1 down-regulation in the early stage of viral infection ameliorated CVB3-induced VMC. In this stage, viral replication was a key point to initiate inflammatory response. ADAR1 may affect inflammation mainly through viral replication as shown by the elevated IFN-β and decreased viral load with ADAR1 down-regulation. However, when the inflammatory response was established in the middle–late stage of viral infection, ADAR1 down-regulation aggravated disease progression. In this stage, Western blot analysis indicated that ADAR1 may directly influence inflammatory response through PKR and NF-κB signaling. Conclusion We demonstrated that ADAR1 exhibited double-edged effects during the early or middle–late stage of CVB3-induced VMC. Our findings may provide new insights into the therapeutic treatments of VMC. [ABSTRACT FROM AUTHOR]

Background Lupus myocarditis is likely more common than recognized clinically due to non-specific symptoms and lack of reliable non-invasive diagnostic tests. We investigated the role of native T1 and T2 in recognition of active myocardial inflammatory involvement in patients with systemic lupus erythematous (SLE). Methods 76 patients with clinically suspected lupus myocarditis (14 males, age: 44 ± 16 years) underwent quantitative tissue characterization with native T1 and T2 mapping. Normotensive healthy subjects taking no medication served as controls (n = 46). Follow-up CMR studies were performed in a total of 35 subjects of which 14 patients received intensified anti-inflammatory treatment, as guided by SLE disease activity. Results Compared to controls SLE patients had higher inflammatory markers, LV mass, native T1 and T2 values, and reduced longitudinal strain (p < 0.01). In patients with a positive troponin test (n = 36; 46%), native T1 and T2 were significantly higher (p < 0.01) with otherwise similar proportions of diffuse perimyocardial LGE (33%) and pericardial effusion (32%). Sixty-nine patients (83%) had an abnormal native T1, whereas 51 (71%) met diagnostic criteria for acute myocarditis. Follow-up CMRs revealed significantly greater reduction in native T1 and T2 values in patients with intensified anti-inflammatory treatment (p < 0.001) with the greatest change observed within the first follow-up period and plateauing thereafter. Native T1 and T2 were significant predictors of treatment response. Conclusions Native T1 and T2 mapping support recognition of lupus myocarditis and reflect the response to anti-inflammatory treatment. Native T1 and T2 mapping may support an effective, noninvasive, radiation- and gadolinium contrast-free screening method for lupus myocarditis. [ABSTRACT FROM AUTHOR]

Background There is a clinical need for immunosuppressive therapy that can treat myocarditis patients in the presence of an active viral infection. In this study we therefore investigated the effects of colchicine, an immunosuppressive drug which has been used successfully as treatment for pericarditis patients, in a mouse model of coxsackievirus B3(CVB3)-induced myocarditis. Methods Four groups of C3H mice were included: control mice (n = 8), mice infected with CVB3 (1 × 10 5 PFU, n = 10), mice with colchicine administration (2 mg/kg i.p, n = 5) and mice with combined CVB3 infection and colchicine administration (n = 10). After three days, the heart, pancreas and spleen were harvested and evaluated using (immuno)histochemical analysis and CVB3 qPCR. Results Mice were terminated at day 3 post-virus infection as colchicine treatment rapidly resulted in severe illness and mortality in CVB3-infected mice. Colchicine significantly decreased the number of macrophages in the heart in CVB3-infected mice (p < 0.01) but significantly increased the number of neutrophils (p < 0.01). In the pancreas, colchicine caused complete destruction of the acini in the CVB3-infected mice and also significantly decreased macrophage (p < 0.01) and increased neutrophil numbers (p < 0.01). In the spleen, colchicine treatment of CVB3-infected mice induced massive apoptosis in the white pulp and significantly inhibited the virus-induced increase of megakaryocytes in the spleen (p < 0.001). Finally, we observed that colchicine significantly increased CVB3 levels in both the pancreas and the heart. Conclusions Colchicine treatment in CVB3-induced myocarditis has a detrimental effect as it causes complete destruction of the exocrine pancreas and enhances viral load in both heart and pancreas. [ABSTRACT FROM AUTHOR]

Cardiac autoimmune reaction takes part in myocarditis, dilated cardiomyopathy and heart failure. Existing literature has confirmed that the occurrence of cardiomyopathy belongs to mitochondrial diseases and is related to the oxidative respiratory chain subunit. The special structure of iron-sulfur protein (ISP) is responsible for the oxidative stress in oxidative phosphorylation, which is also a target that is easily attacked by various damage factors. Using gene therapy technology to restore succinate dehydrogenase iron-sulfur protein (SDISP) function- and thus resume myocardial mitochondria function and myocardial function is hypothesized to alleviate the experimental autoimmunity myocarditis (EAM). [ABSTRACT FROM AUTHOR]

Myocarditis is a heterogeneous group of disorders defined by inflammation of the heart muscle. The primary clinical manifestations of myocarditis are heart failure and sudden death in children and young adults. Numerous interventions have been investigated for the treatment of myocarditis, including broad spectrum alteration of the immune response and antiviral treatments; however, success has been limited. Since the myocarditis treatment trials in the 1990s there has been an improved understanding of disease progression and new facets of the immune response have been discovered. This new information provides fresh opportunities to develop therapeutics to treat myocarditis. This review analyzes previous pharmacologic approaches including immunosuppression, high dose intravenous immunoglobulin treatment, immunoadsorption and antiviral treatments, and looks forward toward recently identified immune factors that can be exploited as targets for new treatments. Such strategies include bolstering beneficial regulatory T cells or mitigating the detrimental Th17 T cells which can drive autoimmunity in the heart. The surging interest of the application of humanized monoclonal antibodies makes targeting deleterious arms of the immune response like Th17 cells a tangible goal in the near future. Promising constituents of herbal remedies have also been identified that may hold potential as new pharmacological treatments for myocarditis, however, significant work remains to elucidate the pharmacokinetics and side-effects of these compounds. Finally, advances in our understanding of the function of Matrix Metalloproteinases yield another target for altering disease progression given their role in the development of fibrosis during Dilated Cardiomyopathy. In bringing to light the various new targets and treatments available since the last myocarditis treatment trials, the aim of this review is to explore the new treatments that are possible in new myocarditis treatment trials. [ABSTRACT FROM AUTHOR]

Berberine, an alkaloid derivative extracted from numerous plants of the general Berberis and Coptis, has been reported to have immunomodulatory effects against immune-mediated disorders in emerging studies. In this study, the effects of berberine and its underlying molecular mechanisms were investigated from the myosin-induced myocardial injury in rats. Lewis rats were immunized with porcine cardiac myosin to induce experimental autoimmune myocarditis (EAM), treated with berberine and specific JAK inhibitor AG490 as a positive control. Our data showed that both berberine and AG490 significantly reduced the impaired cardiac function and the pathophysiological severity, impeded high levels of anti-cardiac myosin antibody of EAM rats. Th17 and Th1 cells as well as their cytokines IL-17 and IFN-γ were up-regulated in EAM. However, the excessive increase of Th17/Th1 responses was restored by berberine and AG490. We also examined the expression level of phosphorylated proteins of JAK-STAT pathway which has a key role in the Th17 and Th1 lineage commitment. The phosphorylated (p)-STAT1,STAT3 and STAT4 increased significantly in EAM, while berberine notably attenuated their excessive expression. This effect of berberine was equivalent to that of AG490 blockade. Our current study demonstrated that berberine could ameliorate EAM and the underling mechanisms may be due to the fact that berberine differentially modulates the activities of p-STAT1, p-STAT3 and p-STAT4 to suppress Th17 and Th1 cell differentiation. [ABSTRACT FROM AUTHOR]

Background Acute fulminant myocarditis with intractable cardiogenic shock is a fatal condition; its only therapeutic option is mechanical circulatory support. The use of mechanical circulatory support, either extracorporeal membrane oxygenation (ECMO) or a ventricular assist device (VAD), serves as a bridge to recovery or as a bridge to transplantation. Objectives The aim of this research was to advance our understanding of the outcome of heart transplantation under mechanical support for acute myocarditis. Two groups of patients were compared: those recovered without undergoing transplantation and those who underwent transplantation. Methods We reviewed 134 patients experiencing acute myocarditis who required mechanical circulatory support (including ECMO and/or VAD) in our institute between 1994 and 2014. Demographic data, clinical characteristics, support duration, and outcome of individuals were retrospectively analyzed. Results Patients taking part in this study were aged from 1 month to 70 years, with an average age of 28 years. The transplantation-free survival rate in adults was 54%. A total of 6 adult patients receive a heart transplant under ECMO/left VAD; 2 of these patients died of uncontrolled sepsis after the heart transplantation. The duration of mechanical support ranged from 10 to 130 days (average, 41 days). Conclusions Mechanical circulatory support in patients with acute myocarditis proved to be effective. Approximately one half of all adult patients in this study experienced myocardium recovery under mechanical support, with only 5% undergoing a successful heart transplantation. In terms of patients who survived after heart transplantation, the mid-term and long-term outcomes are favorable. [ABSTRACT FROM AUTHOR]

Introduction Atrial fibrillation (AF) is a common complication in myocarditis. Atrial inflammation has been suggested to play an important role in the pathophysiology of AF. However, little is known about the occurrence of atrial inflammation in myocarditis patients. Here, we analyzed inflammatory cell numbers in the atria of myocarditis patients without symptomatic AF. Methods Cardiac tissue was obtained postmortem from lymphocytic myocarditis patients ( n = 6), catecholamine-induced myocarditis patients ( n = 5), and control patients without pathological evidence of heart disease ( n = 5). Tissue sections of left and right ventricle and left and right atrium were stained for myeloperoxidase (neutrophilic granulocytes), CD45 (lymphocytes), and CD68 (macrophages). These cells were subsequently quantified in atrial and ventricular myocardium and atrial adipose tissue. Results In lymphocytic myocarditis patients, a significant increase was observed for lymphocytes in the left atrial adipose tissue. In catecholamine-induced myocarditis patients, significant increases were found in the atria for all three inflammatory cell types. Infiltrating inflammatory cell numbers in the atrial myocardium correlated positively with those in the ventricles, especially in catecholamine-induced myocarditis patients. Conclusions To a varying extent, atrial myocarditis occurs concurrently with ventricular myocarditis in patients diagnosed with myocarditis of different etiology. This provides a substrate that potentially predisposes myocarditis patients to the development of AF and subsequent complications such as sudden cardiac death and heart failure. [ABSTRACT FROM AUTHOR]

MicroRNAs (miRNAs) are a group of short, noncoding, regulatory RNA molecules the dysregulation of which contributes to the pathogenesis of myocarditis. Argonaute proteins are essential components of miRNA-induced silencing complex and play important roles during miRNA biogenesis and function. However, the expression pattern of four AGO family members has not yet been detected in the coxsackievirus B3 (CVB3)-induced myocarditis tissue samples. In this study, we detected the expression of four AGOs in the CVB3-infected mouse heart tissues and found that AGO1 and AGO3 up-regulated significantly at 4 and 8 h after CVB3 infection. Further in vitro research indicated that up-regulated AGO1 and AGO3 are related to the down-regulated TNFAIP3, which is a negative regulator of NF-κB pathway. Subsequently, we confirmed that TNFAIP3 is a direct target of miR-19a/b, and during CVB3 infection, the expression of miR-19a/b and miR-125a/b is not significantly changed. TNFAIP3 level is mainly reduced by up-regulated AGO1 and AGO3. This research sheds light on the relationship between overexpressed AGO proteins and CVB3-induced myocarditis, and this provides potential therapeutic target for viral myocarditis. [ABSTRACT FROM AUTHOR]

To investigate the innate immune injury and repair mechanism during recovery from Coxsackievirus B3 (CVB3) induced myocarditis, we established an acute viral myocarditis recovery model by infecting BALB/c mice with CVB3. Histopathological examination of cardiac tissues after infection showed a gradual increase of myocardial injury to the maximum degree at 8 dpi (days post infection), followed by a recovery process with reduced viral replication. We also measured expression changes of innate immune genes in heart after 4, 8 and 12 days of infection using innate immune real-time PCR array. The results showed expression alterations in many Pattern Recognition Receptors (PRRs) genes upon CVB3 infection, which activated multiple important signaling pathways during recovery process. The expression of TLRs, RLRs, PKR and cytokines were strongly induced and reached the peak at 4 dpi in early myocarditis stage, followed by a gradual reduction in recovery stage, during which the levels were even lower than normal at 12 dpi. The strong correlation between cardiac histopathology score and chemokine expression level suggested that the chemokines might play a role in pathological changes during early myocarditis stage. In addition, we also found that both cell survival signaling pathways (AKT1, p38MAPK) and antiviral signaling pathways (IKKα/β/ε) were activated and promoted the recovery during late myocarditis stage. Altogether, our observations improved the understanding of formation and progression of the pathological lesions, as well as the repair mechanism for acute viral myocarditis. [ABSTRACT FROM AUTHOR]

Background Myocarditis, characterized by myocyte necrosis, fibrosis, and degeneration with mononuclear cell infiltration, always causes heart failure in patients. Phosphoinositide 3-kinase (PI3K) is a pivotal kinase known to regulate inflammatory responses in cardiac diseases. Although previous research has suggested that PI3K was involved in cardiac diseases such as myocardial infarction, it is still unclear whether the inhibition of PI3K is essential for the treatment of myosin-induced myocarditis. The aim of this study was to explore whether pharmacological blockade of PI3K is able to protect mice against experimental autoimmune myocarditis (EAM). Materials and methods We used the cardiac myosin-induced murine EAM model to investigate the therapeutic effect of PI3K inhibitor LY294002 on autoimmune myocarditis in mice. Results LY294002 significantly alleviated EAM injury in mice, as indicated by the reduction of cardiac necrosis, inflammatory infiltrates, and CD3 + T cells. LY294002 also decreased the expression of p-Akt upon cardiac myosin treatment in the cardiac tissue of the mice. In the present study, LY294002 resulted in a moderate reduction in absolute CD4 + cell numbers and a significant decrease in the absolute numbers of CD8 + cells. Consequently, LY294002 increased the CD4 + /CD8 + ratio compared with peptide treatment alone. Conclusion This report provides evidence that PI3K inhibitor LY294002 has potent effects against cardiac injury caused by EAM, suggesting that it has therapeutic value for the treatment of myocarditis. [ABSTRACT FROM AUTHOR]

Giant cell myocarditis (GCM) is an aggressive inflammatory myocardial disease. Immunosuppression is an effective treatment for some cases. However, the duration of action of agents such as muromonab CD3 is short and others such as the calcineurin inhibitors may lead to renal failure. Here we describe the outcome of a novel approach to treatment using rabbit anti-thymocyte globulin (RATG). A retrospective analysis of 6 patients treated with RATG for GCM was performed. Diagnosis was confirmed by endomyocardial biopsy, and RATG was administered with a high dose of corticosteroids. None of the patients had cytokine release syndrome or leukopenia, and 5 had thrombocytopenia (2 of them severe). Only 1 had a serious bleeding event that occurred after implantation of mechanical circulatory support. None developed impaired renal function after the treatment. Five were successfully discharged home with an increase in global left ventricular ejection fraction of 29%. Four are currently alive without recurrent disease, 1 of them after heart transplantation, with a mean follow-up of 970 days (423 to 1,875 days), left ventricular ejection fraction of 53%, and all in current New York Heart Association Classification class ≤II. Only 1 case had GCM recurrence. There were 2 deaths: one because of intracranial bleeding after mechanical circulatory support implantation and the other caused by primary graft dysfunction. In conclusion, patients with GCM can be successfully immunosuppressed with RATG and corticosteroids, thereby avoiding renal impairment. Early thrombocytopenia is the main adverse event. Larger cohorts of patients are necessary to compare the different immunosuppressant strategies available for GCM in a randomized fashion. [ABSTRACT FROM AUTHOR]

Giant cell myocarditis (GCM) is a rare disorder in which survival beyond 1 year without heart transplantation is uncommon. Long-term follow-up data on those with such survival are lacking. Twenty-six patients with biopsy-proved GCM who survived for >1 year without heart transplantation were identified from a multicenter GCM registry. The incidence of death, transplantation, ventricular assist device placement, and histologically proved disease recurrence was ascertained retrospectively. The rates of recurrent heart failure, ventricular arrhythmias, renal failure, and infectious complications were calculated. The mean age of the cohort was 54.6 ± 13.9 years (65% women). The mean follow-up duration was 5.5 years starting 1 year after diagnosis. There were 3 deaths (12%), 5 heart transplantations (19%), and 1 ventricular assist device placement (4%). Three histologically confirmed recurrences of GCM (12%) occurred between 1.5 and 8 years after diagnosis. Thirteen of 26 patients experienced a total of 30 heart failure episodes ≥1 year after initial diagnosis. There were 23 episodes of elevated creatinine in 12 patients, 41 infectious events in 13 patients, and 19 episodes of ventricular arrhythmias in 6 patients with a total of 144 years of follow-up. Starting 1 year after GCM diagnosis, the combined rate of death, transplantation, ventricular assist device placement, and GCM recurrence was 47% at 5 years. In conclusion, the risk for GCM recurrence continues to ≥8 years after diagnosis. [ABSTRACT FROM AUTHOR]

We demonstrated an extremely unusual case of an 83-year-old male's sudden death secondary to characteristic myocardial necrosis and fibrosis with calcification and multinucleated giant cells infiltration, possibly due to sepsis and Stage IV pulmonary pleomorphic carcinoma-induced cachexia after postmortem study. We propose that this calcifying giant cell cardiomyopathy (CGC) would be a new entity especially from the pathological viewpoints and should be considered in the classification of noninfectious myocarditis. Further prospective studies are needed to validate the presence and significance of CGC and the association with any triggers of somewhat microvascular dysfunction and/or toxic agents, after collecting and investigating a larger number of CGC cases examined. [ABSTRACT FROM AUTHOR]

Coxsackievirus B type 3 (CVB3) is one of the major causative pathogens associated with viral meningitis and myocarditis, which are widespread in the human population and especially prevalent in neonates and children. These infections can result in dilated cardiomyopathy (DCM) and other severe clinical complications. There are no vaccines or drugs approved for the prevention or therapy of CVB3-induced diseases. During screening for anti-CVB3 candidates in our previous studies, we found that jiadifenoic acids C exhibited strong antiviral activities against CVB3 as well as other strains of Coxsackie B viruses (CVBs). The present studies were carried out to evaluate the antiviral activities of jiadifenoic acids C. Results showed that jiadifenoic acids C could reduce CVB3 RNA and proteins synthesis in a dose-dependent manner. Jiadifenoic acids C also had a similar antiviral effect on the pleconaril-resistant variant of CVB3. We further examined the impact of jiadifenoic acids C on the synthesis of viral structural and non-structural proteins, finding that jiadifenoic acids C could reduce VP1 and 3D protein production. A time-course study with Vero cells showed that jiadifenoic acids C displayed significant antiviral activities at 0-6h after CVB3 inoculation, indicating that jiadifenoic acids C functioned at an early step of CVB3 replication. However, jiadifenoic acids C had no prophylactic effect against CVB3. Taken together, we show that jiadifenoic acids C exhibit strong antiviral activities against all strains of CVB, including the pleconaril-resistant variant. Our study could provide a significant lead for anti-CVB3 drug development. Jiadifenoic acids C exhibit strong antiviral activities against all coxsackievirus B types including pleconaril-resistant CVB3 variant. Results show that it could reduce CVB3 viral RNA and protein synthesis in a dose-dependent manner and the potential targets may be relevant with viral proteins VP1 and 3D. [ABSTRACT FROM AUTHOR]

Efficient delivery of antigen to mucosal associated lymphoid tissue is a first and critical step for successful induction of mucosal immunity by vaccines. Considering its potential transcytotic capability, M cell has become a more and more attractive target for mucosal vaccines. In this research, we designed an M cell-targeting strategy by which mucosal delivery system chitosan (CS) was endowed with M cell-targeting ability via conjugating with a CPE30 peptide, C terminal 30 amino acids of clostridium perfringens enterotoxin (CPE), and then evaluated its immune-enhancing ability in the context of coxsackievirus B3 (CVB3)-specific mucosal vaccine consisting of CS and a plasmid encoding CVB3 predominant antigen VP1. It had shown that similar to CS-pVP1, M cell-targeting CPE30-CS-pVP1 vaccine appeared a uniform spherical shape with about 300nm diameter and +22mV zeta potential, and could efficiently protect DNA from DNase I digestion. Mice were orally immunized with 4 doses of CPE30-CS-pVP1 containing 50μg pVP1 at 2-week intervals and challenged with CVB3 4 weeks after the last immunization. Compared with CS-pVP1 vaccine, CPE30-CS-pVP1 vaccine had no obvious impact on CVB3-specific serum IgG level and splenic T cell immune responses, but significantly increased specific fecal SIgA level and augmented mucosal T cell immune responses. Consequently, much milder myocarditis and lower viral load were witnessed in CPE30-CS-pVP1 immunized group. The enhanced immunogenicity and immunoprotection were associated with the M cell-targeting ability of CPE30-CS-pVP1 which improved its mucosal uptake and transcytosis. Our findings indicated that CPE30-CS-pVP1 may represent a novel prophylactic vaccine against CVB3-induced myocarditis, and this M cell-targeting strategy indeed could be applied as a promising and universal platform for mucosal vaccine development. [ABSTRACT FROM AUTHOR]

Abstract: Background: Myocarditis can be difficult to diagnose in the Emergency Department (ED) due to the lack of classic symptoms and the wide variation in presentations. Poor cardiac contractility is a common finding in myocarditis and can be evaluated by bedside ultrasound. Objective: To demonstrate the utility of fractional shortening measurements as an estimation of left ventricular function during bedside cardiac ultrasound evaluation in the ED. Case Report: A 54-year-old man presented to the ED complaining of 3 days of chest tightness, palpitations, and dyspnea, as well as persistent abdominal pain and vomiting. An electrocardiogram (ECG) showed sinus tachycardia with presumably new ST-segment elevation and signs of an incomplete right bundle branch block. A bedside echocardiogram was performed by the emergency physician that showed poor left ventricular function by endocardial fractional shortening measurements. On further questioning, the patient revealed that for the past 2 weeks he had been regularly huffing a commercially available compressed air duster. Based on these history and examination findings, the patient was given a presumptive diagnosis of toxic myocarditis. A follow-up echocardiogram approximately 7 weeks later demonstrated resolution of the left ventricular systolic dysfunction and his ECG findings normalized. Conclusion: Cardiac ultrasound findings of severely reduced global function measured by endocardial fractional shortening were seen in this patient and supported the diagnosis of myocarditis. Endocardial fractional shortening is a useful means of easily evaluating and documenting left ventricular function and can be performed at the bedside in the ED. [Copyright &y& Elsevier]

Abstract: Background: Recent evidence suggests that erythromycin (EM), a major macrolide antibiotic, has many biological functions in addition to the anti-bacterial actions, including anti-inflammatory and free radical scavenging actions. However, the effects of the drug upon inflammatory myocardial diseases are unknown. We tested the hypothesis that EM ameliorates experimental autoimmune myocarditis in rats attributing to the suppression of superoxide production. Methods: We administered EM, 3.3mg/kg/day and 33mg/kg/day, intraperitoneally for 3weeks, to rats with experimental autoimmune myocarditis (EAM) produced by immunization by porcine myosin. Results: EM treatment reduced the severity of myocarditis compared with the untreated group in a dose-dependent manner by comparing the heart weight/body weight ratio, pathologic scores, and myocardial macrophage, CD4+, and CD8+ infiltrations. Echocardiographic study showed that increased left ventricular posterior wall thickness produced by myocardial inflammation was reduced by EM treatment. Myocardial superoxide production, determined by dihydroethidium staining, was significantly reduced by the treatment. Western blotting showed that the expression of myocardial interleukin-1β was reduced by EM treatment compared with untreated groups. The in vivo dorsal air pouch model showed that EM significantly suppressed leukocyte chemotaxis in a dose-dependent manner. Conclusion: Irrespective of a well-known classic antibiotic, EM attenuated EAM not only by the anti-inflammatory action but by the suppression of superoxide production. [Copyright &y& Elsevier]

Heart transplantation (HT) for myocarditis has been controversial because of earlier reports of a poor prognosis after the procedure. We sought to determine whether lymphocytic myocarditis (LM) at the time of HT affects cardiac allograft rejection and survival after HT compared with other patients without LM in the current era of HT. We retrospectively reviewed 759 consecutive patients who underwent de novo HT at Columbia University Medical Center between 2000 and 2010 and compared prognosis after HT of the patients with pathologically proven LM in their explanted hearts with that of age- and gendermatched patients with idiopathic dilated cardiomyopathy (IDC group; n = 96) and with ischemic cardiomyopathy (IC group; n = 64). Thirty-two patients (4.2%) had LM in the explanted hearts pathologically. Among the 3 groups, no statistically significant difference was observed in the number of biopsy-diagnosed acute cellular rejection (ACR; International Society for Heart & Lung Transportation grade ≥2R) events during the first year after HT. In contrast, the frequency of biopsy-diagnosed ACR in subsequent years was greater in the LM group (n = 8, 3.8%) than in IC group (n = 3, 0.5%, p = 0.006), although no different from that of patients with IDC. The frequency of antibody-mediated rejection and posttransplant survival did not differ among the 3 groups. In conclusion, patients with pre-HT LM have an increased frequency of late ACR after HT compared with patients with IC. Nevertheless, survival of LM patients after HT is comparable to that of patients transplanted for IDC or IC. [ABSTRACT FROM AUTHOR]

Abstract: Background: Human herpesvirus 6 (HHV-6) is an important cause of fulminant or acute viral myocarditis. However, insufficiency of standard antiviral treatment against HHV-6 is an emerging problem. Objectives: To describe the case of child with HHV-6 myocarditis who was treated by unloading with a left ventricular assist device and Artesunate. Study design: Case report supported by histological and viral diagnoses via a combination of histology/immunohistochemistry and polymerase chain reaction techniques performed on cardiac tissues before and after treatment. Results: Following therapeutic intervention, the clinical status and heart function improved. Endomyocardial biopsies revealed decreased levels of HHV-6B DNA in the myocardium and the disappearance of histological findings in support of lymphocytic myocarditis. Left ventricular assist device could be explanted. No adverse effects of Artesunate were noted. Conclusions: In addition to existing heart failure treatments, Artesunate can be considered as an effective candidate for clinical use in cases of HHV-6B associated myocarditis. [Copyright &y& Elsevier]

Abstract: Human parainfluenza virus (HPIV) infection as an aetiology of acute viral myocarditis is rare, with only few cases reported in the literature to date. Here we report a case of fulminant HPIV-2 myocarditis in a 47 year-old man with viraemia who was successfully treated with intravenous ribavirin and intravenous immunoglobulin (IVIG). There are currently no recommendations on the treatment of HPIV myocarditis. We are, to our knowledge, the first to report a patient with a documented HPIV-2 viraemia that subsequently cleared after the initiation of antiviral therapy. Although it is difficult to definitively attribute the patient''s clinical improvement to ribavirin or IVIG alone, our case does suggest that clinicians may wish to consider initiating ribavirin and IVIG in patients with HPIV myocarditis and persistent viraemia not responding to supportive measures alone. [Copyright &y& Elsevier]

Abstract: Early experiments showed cinnamaldehyde had obvious therapeutic effect on viral myocarditis, but cinnamaldehyde was unstable in vivo. To overcome this limitation, we used cinnamaldehyde as a lead compound to synthesize α-bromo-4-chlorocinnamaldehyde (BCC). In the present study, we compared the therapeutic effects of BCC with cinnamaldehyde on coxsackie virus B3 (CVB3)-induced viral myocarditis (VMC), as well as investigated the possible mechanism. The antiviral and cytotoxic effects in vitro were evaluated on HeLa cells infected by CVB3 and rat cardiomyocytes respectively. Our results showed that IC50 were 0.78±0.13μM and 48.16±5.79μM in BCC and cinnamaldehyde-treated cells. 50% toxic concentration (TC) in BCC-treated cells was 22-fold higher than in the cinnamaldehyde group. In vivo BALB/c mice were infected with CVB3 for establishing VMC models. The results demonstrated that BCC reduced the viral titers and cardiac pathological changes in a dose-dependent manner. Myocardial virus titers were significantly lower in the 50mg/kg BCC-treated group than in cinnamaldehyde groups. In addition, BCC could significantly inhibit the replication of CVB3 mRNA and the secretion of inflammatory cytokines TNF-α, IL-β and IL-6 in CVB3-infected cardiomyocytes. We further observed that BCC suppressed CVB3-induced NF-κB activation, IκB-α degradation and phosphorylation in a concentration-dependent manner, and reduced Toll like receptor (TLR) 4 protein level in hearts. These results suggest that BCC had a promising therapeutic effect on VMC with a highly significant favorable effects and less toxicity than cinnamaldehyde. Furthermore, the effect of BCC on VMC might be through inhibition of inflammatory signaling. [Copyright &y& Elsevier]

Abstract: Our previous researches showed that nitronyl nitroxyl derivatives, NNP and NNVP were good anti-oxidants and provided radioprotective effects in C6 cells. The objective of the present study is to investigate the possible antiviral effects and underlying pharmacological of the two nitronyl nitroxide radicals against CVB3 in vitro and in vivo. The results showed that NNP and NNVP were some of the most potent compounds in terms of their antiviral effects by protecting myocardial cells against oxidative damage of free radicals. Treatment with NNP or NNVP could decrease the intracellular ROS level in vitro. They could lead to a significant decrease in activities of biochemical markers AST, CK and LDH in infected murine serum and could increase SOD and CAT activities and decreased MDA activities compared with infected control in vivo. NNP and NNVP could reduce NO production in infected mice by reacting with NO to produce the imino nitroxides which was confirmed by ESR spectrometry. In addition, NNP and NNVP could both decrease the mRNA expression of proinflammatory cytokines, TNF-α, IL-2 and IL-6. In conclusion, nitronyl nitroxide radicals NNP and NNVP were shown to have antiviral activities against CVB3 and they may represent potential therapeutic agents for viral myocarditis. [Copyright &y& Elsevier]

Abstract: IL-12 plays an important role in the treatment of many infectious diseases by being administered intravenously or intramuscularly. However, intravenous or intramuscular administration is difficult and inconvenient and may cause side effects. The aim of this study is to develop a novel oral delivery system for IL-12 using genetically engineered Bifidobacterium longum as the carrier and further investigate the efficacy of IL-12-expressed B. longum on the coxsackie virus B3 (CVB3)-induced myocarditis in mice. A mIL-12 gene expression vector pBBADs-IL-12 for B. longum was constructed and transformed into Bifidobacterium. Subsequently, the expression of mIL-12 in the engineered B. longum was identified in vitro by western blot and enzyme-linked immunosorbent assay (ELISA) after l-arabinose induction. Moreover, our data indicated that oral administration of IL-12-expressed B. longum for two weeks after CVB3 infection in the Balb/c mice could downregulate the severity of virus-induced myocarditis, markedly reduce the virus titers in the heart and induce a Th1 pattern in the spleen and heart compared with the controls. In conclusion, a novel oral delivery system of Bifidobacterium for murine IL-12 has been successfully established. Oral administration of mIL-12-transformed B. longum may play a therapeutic role in the treatment of CVB3-induced myocarditis in the mice. [Copyright &y& Elsevier]

Abstract: A 4-year old female spayed domestic short hair cat presented for evaluation of a tachyarrhythmia identified on routine physical examination. Supraventricular tachycardia (SVT) was identified on electrocardiogram (ECG). Echocardiogram failed to identify any structural heart disease. A positive Bartonella antibody titer was identified on serological evaluation. The cat received anti-arrhythmics for control of the SVT and azithromycin for Bartonella. After completion of antibiotic therapy, a four-fold decrease in the Bartonella antibody titer was measured and the cat was eventually weaned off anti-arrhythmic medications. At 1 week, 1 month and 3 month re-checks off all therapy, no SVT was identified. [Copyright &y& Elsevier]

Abstract: Myocarditis comprises a large proportion of pediatric cardiomyopathies. Viruses most commonly cause pediatric myocarditis but the diagnosed frequency of specific viruses that are responsible for pediatric myocarditis continues to evolve over time. A recent Pediatric Cardiomyopathy Registry (PCMR) analysis in the largest group of pediatric myocarditis patients ever studied confirmed that the most common outcome in pediatric myocarditis is cardiac recovery, but a substantial group of patients die or require heart transplantation after contracting the disease. A limited number of biomarkers associated both good (recovery) and poor (death or transplantation) outcomes could be identified. Immunosuppressive/immunomodulating therapy for pediatric myocarditis remains controversial with both proponents and adversaries. While small case series have shown benefit of these therapies in pediatric myocarditis, the high rate of spontaneous improvement with supportive care may make the definitive proof of efficacy in future clinical trials problematic. The effect of immune globulin on the outcome of pediatric myocarditis is uncertain. Myocarditis is the underlying disease leading to heart transplantation in a considerable number of children, but recent evidence from the PCMR and Pediatric Heart Transplant Study (PHTS) merged dataset suggests that their outcomes are poorer than for other cardiomyopathies after transplant. The increased availability of pediatric ventricular assist devices in North America may provide an opportunity to more effectively bridge critically ill myocarditis patients to transplantation and, more dramatically, to recovery. [Copyright &y& Elsevier]

Abstract: Oxidative stress has been implicated in the pathogenesis of acute myocarditis. The imbalance between the occurrence of reactive oxygen species and the cellular antioxidant defense mechanism plays a key role in myocardial injury of viral myocarditis. Carvedilol, a nonselective β-adrenoceptor antagonist with additional α1-adrenergic blocking and antioxidant properties, has been shown to be cardioprotective in experimental myocarditis. However, the expression of 4-hydroxy-2-nonenal (4-HNE), the most reliable marker of lipid peroxidation, has not been studied, and the antioxidative effects of carvedilol have not been investigated in the setting of acute viral myocarditis. This study was therefore designed to determine whether levels of lipid peroxides are elevated in the myocardium and whether carvedilol reduces the lipid peroxidation level and increases antioxidant enzyme activities. In a coxsackievirus B3 murine myocarditis model (Balb/c), effects of carvedilol and metoprolol on 14-day survival rate, myocardial histopathological changes, cardiac function, the expression of 4-HNE, virus titers, malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidases (GSH-Px) activities were studied. Lipid peroxidations including 4-HNE and MDA, were elevated in murine coxsackievirus-induced acute viral myocarditis. Carvedilol, but not metoprolol, improved survival, reduced lipid peroxidations including 4-HNE and MDA, and increased antioxidant enzyme activities including SOD and GSH-Px with amelioration of acute viral myocarditis. These results show that carvedilol but not metoprolol exerts some of its beneficial effects by inhibiting peroxidants. [Copyright &y& Elsevier]

Aim of study: The heart-protective effect and mechanism of Qishaowuwei formula (QSW), a Traditional Chinese Medicine formula composed of Radix Astragali, Radix Paeoniae Rubra and Fructus Schisandrae was investigated on murine model of viral myocarditis (VMC) induced by Coxsackievirus B3 (CVB3). Materials and methods: Mice were randomly divided into infected control group, QSW high dose group, QSW medium dose group, QSW low dose group and Vitamin C plus Ribavirin treatment group. 50 mice were included in each group. The day of virus inoculation was defined as day 0 and the drug treatment continued once a day for 14 days. Mice were sacrificed on days 3, 7, 14, 21 postinoculation (p.i.). The histopathological changes of myocardium, CVB3 RNA copies in the myocardium, cardiomycytic apoptosis, the serum level of superoxide dismutase (SOD) and maleic dialdehyde (MDA) and the phenotype of T lymphocytes subsets in peripheral blood was analyzed. Results: QSW treatment significantly increase the survival rate (p <0.05) in VMC model. Histopathology and flow cytometry inspection revealed low ratio of cardiomyocytes necrosis and apoptosis in QSW treated mice with dose dependent manner. The cardiomyocytic ultra-structure observed by transmission electron microscope also supported the above results. The ameliorated tissue damage was consistent with reduced CVB3 copy numbers detected by real-time PCR in the myocardium of QSW treated mice. The antioxidant effect of QSW was proved by elevated activity of SOD and reduced level of MDA in the serum. Furthermore, the disturbed balance of CD4+ and CD8+ subsets in peripheral blood was restored. Conclusion: These results demonstrated QSW had potent protective effect against CVB3-induced heart injury and this effect might be mediated by its inhibition on viral replication, antioxidant activity and immunoregulation mechanism. [Copyright &y& Elsevier]

There is much debate over the role of immunosuppression in the treatment of acute and fulminant myocarditis. The low incidence of the condition prevents large numbers of cases for study, and treatment protocols vary greatly between institutions. In this study we add our experience with anti-thymocyte globulin as an adjunct to standard medical therapy for 5 patients presenting with cardiogenic shock due to fulminant myocarditis. All cases were associated with rapid and dramatic improvement in hemodynamic and electrophysiologic abnormalities, returning patients to NYHA Class I and cardiac function to normal or near normal by discharge. [Copyright &y& Elsevier]

Myocarditis, an inflammatory disease of heart muscle, Is an Important cause of dilated cardiomyopathy worldwide. Viral infection is also an important cause of myocarditis, and the spectrum of viruses known to cause myocarditis has changed in the past 2 decades. Several new diagnostic methods, such as cardiac magnetic resonance imaging, are useful for diagnosing myocarditis. Endomyocardial biopsy may be used for patients with acute dilated cardiomyopathy associated with hemodynamic compromise, those with life-threatening arrhythmia, and those whose condition does not respond to conventional supportive therapy. important prognostic variables include the degree of left and right ventricular dysfunction, heart block, and specific histopathological forms of myocarditis. We review diagnostic and therapeutic strategies for the treatment of viral myocarditis. English-language publications in PubMed and references from relevant articles published between January 1, 1985, and August 5, 2008, were analyzed. Main keywords searched were myocarditis, dilated cardiomyopathy, endomyocardial biopsy, cardiac magnetic resonance Imaging, and Immunotherapy. [ABSTRACT FROM AUTHOR]

Abstract: Aims: The aim of study is to investigate the effect of nifedipine on viral myocarditis in an animal model. Main methods: Four-week-old male DBA/2 mice were inoculated with 2 pfu of encephalomyocarditis virus (EMCV) and randomized to nifedipine (n =10) or control (n =10) group. The control group was fed by regular chow and the nifedipine group contained 0.01% of nifedipine. Mast cell density was counted, and expressions of messenger RNAs of stem cell factor (SCF), matrix metalloproteinases (MMPs), pro-collagen I, mast cell proteases, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were evaluated by RT-PCR. Key findings: The area of myocardial necrosis was smaller in the nifedipine vs the control group (mean±SD, 1.2±1.3% vs 3.8±1.8%, respectively, P <0.005). The mast cell density (count/mm2) was lower in the nifedipine vs the control group (mean±SD, 0.23±0.16 vs 1.08±0.45, respectively, P <0.0005). The expressions of MMPs, mast cell proteases, TNF-α, IL-6, SCF and pro-collagen I were lower in the nifedipine group than in the control group (P <0.05). Significance: Nifedipine inhibited the activation of various participants in inflammatory and immune reactions in EMCV myocarditis. [Copyright &y& Elsevier]

An 8-month-old boy with acute myocarditis was mechanically supported with the Berlin Heart EXCOR biventricular assist device. Signs of myocardial recovery were not apparent until 40 days from presentation and ventricular function continued to improve with device removal possible after 120 days of support. He had normal cardiac function 3 months after device removal. Recovery from myocarditis in infants can take much longer than previously recognized and an extended wait for recovery is possible with the Berlin Heart. [Copyright &y& Elsevier]

Giant cell myocarditis (GCM) is a rare and highly lethal disorder. The only multicenter case series with treatment data lacked cardiac function assessments and had a retrospective design. We conducted a prospective, multicenter study of immunosuppression including cyclosporine and steroids for acute, microscopically-confirmed GCM. From June 1999 to June 2005 in a standard protocol, 11 subjects received high dose steroids and cyclosporine, and 9 subjects received muromonab-CD3. In these, 7 of 11 were women, the mean age was 60 ± 15 years, and the mean time from symptom onset to presentation was 27 ± 33 days. During 1 year of treatment, 1 subject died of respiratory complications on day 178, and 2 subjects received heart transplantations on days 2 and 27, respectively. Serial endomyocardial biopsies revealed that after 4 weeks of treatment the degree of necrosis, cellular inflammation, and giant cells decreased (p = 0.001). One patient who completed the trial subsequently died of a fatal GCM recurrence after withdrawal of immunosuppression. Her case demonstrates for the first time that there is a risk of recurrent, sometimes fatal, GCM after cessation of immunosuppression. In conclusion, this prospective study of immunosuppression for GCM confirms retrospective case reports that such therapy improves long-term survival. Additionally, withdrawal of immunosuppression can be associated with fatal GCM recurrence. [Copyright &y& Elsevier]

Abstract: Radix Astragali, a Chinese medicinal herb, consists of polysaccharides and flavonoids as its main active ingredients. It has been widely used for treatment of cardiovascular diseases such as heart failure, angina pectoris, myocardial infarction and stroke in Asian countries. This study was designed to evaluate the effect of Radix Astragali on myocardial dysfunction, cardiac remodeling and morphological alteration in an experimental model of autoimmune myocarditis, a clinical condition often resulting in dilated cardiomyopathy. Experimental autoimmune myocarditis was established with a subcutaneous injection of porcine cardiac myosin into rear footpad in Lewis rats. Radix Astragali treatment was delivered via an intravenous injection (0.2ml/100g body weight, daily) for 3 weeks. Results from transthoracic echocardiography indicated that experimental autoimmune myocarditis led to impaired myocardial contractile function which was reconciled by Radix Astragali. The experimental autoimmune myocarditis triggered profound inflammation and fibrosis in myocardium as assessed by hematoxylin and eosin (H and E) and Masson’s trichrome staining. Interestingly, Radix Astragali significantly attenuated autoimmune myocarditis-induced myocardial inflammation and fibrosis. Similarly, Radix Astragali treatment alleviated autoimmune myocarditis-triggered overt lymphocyte proliferation. Furthermore, Radix Astragali significantly attenuated elevated levels of the Th1 cytokines (IFN-γ and IL-2), and increased the Th2 cytokines (IL-4 and IL-10) in autoimmune myocarditis. Collectively, our data revealed that Radix Astragali effectively protected against cardiac functional and morphological aberrations in experimental autoimmune myocarditis. [Copyright &y& Elsevier]

Background: Myocardial edema is a substantial feature of the inflammatory response in human myocarditis. The relation between myocardial edema and myocardial mass in the course of healing myocarditis has not been systematically investigated. We hypothesised that the resolution of myocardial edema as visualised by T2-weighted cardiovascular magnetic resonance (CMR) is associated with a decrease of myocardial mass in steady state free precession (SSFP)-cine imaging. Methods: 21 patients with acute myocarditis underwent CMR shortly after onset of symptoms and 1 year later. For visualization of edema, a T2-weighted breath-hold black-blood triple-inversion fast spin echo technique was applied and the ratio of signal intensity of myocardium/skeletal muscle was assessed. Left ventricular (LV) mass, volumes and function were quantified from biplane cine steady state free precession images. 11 healthy volunteers served as a control group for interstudy reproducibility of LV mass. Results: In patients with myocarditis, a significant decrease in LV mass was observed during follow-up compared to the acute phase (156.7 ± 30.6 g vs. 140.3 ± 28.3 g, p < 0.0001). The reduction of LV mass paralleled the normalization of initially increased myocardial signal intensity on T2-weighted images (2.4 ± 0.4 vs. 1.68 ± 0.3, p < 0.0001). In controls, the interstudy difference of LV mass was lower than in patients (5.1 ± 2.9 g vs. 16.3 ± 14.2 g, p = 0.02) resulting in a lower coefficient of variability (2.1 vs 8.9%, p = 0.04). Conclusion: Reversible abnormalities in T2-weighted CMR are paralleled by a transient increase in left ventricular mass during the course of myocarditis. Myocardial edema may be a common pathway explaining these findings. [ABSTRACT FROM AUTHOR]

We describe a patient with acute necrotizing eosinophilic myocarditis who recovered rapidly after pericardial drainage and without corticosteroid therapy. The 25-year-old man was referred to our hospital with suspected acute myocardial infarction on the basis of severe epigastralgia, abnormal Q waves and ST elevation on electrocardiography, and an increase in cardiac enzymes. Echocardiography disclosed pericardial effusion that compressed the right ventricle, left ventricular dysfunction in conjunction with posterolateral hypokinesis, and a thickened ventricular wall but no mural thrombus. The eosinophil count in the peripheral blood was slightly increased. Coronary angiography showed normal arteries and thus prompted an endomyocardial biopsy. The patient was transferred to the intensive care unit with a clinical diagnosis of myocarditis associated with cardiac tamponade. Emergency pericardiocentesis relieved symptoms immediately. The cells in the pericardial effusion were mainly eosinophils; interleukin 5 and interleukin 13 levels were predominantly elevated, and the effusion was drained for 5 days. The biopsy specimen revealed necrotizing eosinophilic myocarditis. Left ventricular function recovered within a week without corticosteroid therapy. No relapse was observed as of 8 months after diagnosis. [ABSTRACT FROM AUTHOR]

Percutaneous cardiopulmonary support was used in 9 patients with fulminant myocarditis and cardiogenic shock. Although 2 of the patients died, 7 improved and were able to resume social activities. Percutaneous cardiopulmonary support should be administered routinely to patients with fulminant myocarditis developing into cardiogenic shock. [ABSTRACT FROM AUTHOR]

Summary: Although a large number of different causes have been identified as leading to myocarditis, inflammation plays a pivotal role in its pathological process. No specific methods are available in the therapy of myocarditis except symptomatic treatment. Vagus nerve stimulation has been found to lower the heart rate and recover the normal heart rhythm which may relieve the cardiac symptoms in myocarditis. Furthermore, the acetylcholine that secreted by vagus nerve stimulation was found to inhibit the production of such inflammatory cytokines as tumor necrosis factor-α (TNF-α), interleukin 1β (IL-1β). Based on the above, we hypothesized that vagus nerve stimulation can be used in the therapy of myocarditis and lead to relief of symptoms and inhibition of inflammatory process which may kill two birds with one stone. [Copyright &y& Elsevier]