Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support

Annals of Intensive Care · 22 authors, 8 centres

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This retrospective cohort study of 47 ICU patients with fulminant myocarditis on mechanical circulatory support found that myocardial biopsy increased the diagnostic classification of definite myocarditis but was associated with significant complications and a low rate of treatment change leading to recovery.

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The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after biopsy results. The biopsy increased the definite myocarditis classification from 13% to 55% (p < 0.0001). Safety analysis showed tamponade requiring emergency pericardiocentesis in 29% of patients after endomyocardial biopsy. Treatment modifications based on biopsy results occurred in 13% of patients, but these led to recovery in only 4% of cases. Overall mortality was 55%, with 34% bridged-to-recovery and 15% bridged-to-transplant.

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cohort

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cardiology

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ORIGINAL PAPER

PMC10471530

Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support

Annals of Intensive Care

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ABSTRACT

Abstract Background Fulminant myocarditis is a rare and severe disease whose definite and etiological diagnoses rely on pathological examination. Albeit, myocardial biopsy can be associated with significant morbidity and mortality, its therapeutic consequences are unclear. We conducted a study to determine the diagnostic yield, the safety and the therapeutic consequences of myocardial biopsy in patients with fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (MCS). Methods Monocenter, retrospective, observational cohort study in a 26-bed French tertiary ICU between January 2002 and February 2019. Inclusion of all fulminant clinically suspected myocarditis patients undergoing in-ICU myocardial biopsy while being on MCS. The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results. Results Forty-seven patients (median age 41 [30–47], female 53%) were included: 55% died before hospital discharge, 34% could be bridged-to-recovery and 15% bridged-to-transplant. Myocardial biopsy was endomyocardial or surgical in 36% and 64% cases respectively. Tamponade requiring emergency pericardiocentesis occurred in 29% patients after endomyocardial biopsy. After adding the biopsy results in the Bonaca classification algorithm the percentage of definite myocarditis raised from 13 to 55% (p < 0.0001). The rate of biopsy-related treatments modifications was 13%, leading to patients’ recovery in only 4% patients. Conclusions In clinically suspected myocarditis unweanable from MCS, myocardial biopsy increased the rate of definite myocarditis but was associated with a low rate of treatment modification and a significant proportion of adverse events. We believe the benefit/risk ratio of myocardial biopsy should be more carefully weighted in these frail and selected patients than suggested by actual guidelines. Further prospective studies are now needed to determine its value in patients under MCS. Graphical Abstract Supplementary Information The online version contains supplementary material available at 10.1186/s13613-023-01169-y. Keywords: Fulminant myocarditis, Mechanical circulatory support, Endomyocardial biopsy, Diagnostic yield, Extracorporeal membrane oxygenation, Clinically suspected myocarditis

CITATION EXPORT

Yann Marquet, Guillaume Hékimian, Guillaume Lebreton et al.. Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support. Annals of Intensive Care. (2023). https://doi.org/10.1186/s13613-023-01169-y

AUTHORS

22 · 8 CENTRES

Yann Marquet, Guillaume Hékimian, Guillaume Lebreton, Mathieu Kerneis, Philippe Rouvier, Pierre Bay, Alexis Mathian, Nicolas Bréchot, Juliette Chommeloux, Matthieu Petit, Melchior Gautier, Lucie Lefevre, Ouriel Saura, David Levy, Paul Quentric, Quentin Moyon, Sofia Ortuno, Matthieu Schmidt, Pascal Leprince, Charles-Edouard Luyt, Alain Combes, Marc Pineton de Chambrun

1Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié–Salpêtrière, 47–83, Boulevard de l’Hôpital, 75651 Paris Cedex, France
2Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013 Paris, France
3Service de Chirurgie Cardio-Thoracique, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié–Salpêtrière, Paris, France
4ACTION Study Group, Département de Cardiologie, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Paris, France
5Service d’Anatomopathologie, Sorbonne Université, APHP, Hôpital La Pitié–Salpêtrière, Paris, France
6AP-HP, Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation and UPEC (Université Paris Est), INSERM, Unité U955, Équipe 18, 94010 Créteil, France
7Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié–Salpêtrière, Institut E3M, Paris, France
8Sorbonne Université, Inserm, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France