Krejci Jan, Hude Petr, Poloczkova Hana, Zampachova Vita, Stepanova Radka, Freiberger Tomas, Nemcova Eva, Spinarova Lenka
Department of Cardiovascular Diseases, St. Anne's University Hospital, International Clinical Research Center, Pekarska 53, 65690, Brno, Czech Republic.
Masaryk University, Brno, Czech Republic.
Heart Vessels. 2016 Mar;31(3):416-26. doi: 10.1007/s00380-014-0618-0. Epub 2014 Dec 25.
Patients with myocarditis and left ventricular (LV) dysfunction may improve after standard heart failure therapy. This improvement seems to be related to retreat of myocardial inflammation. The aim of the present study was to assess changes in clinical, echocardiographic and some laboratory parameters and to correlate them with changes in the number of inflammatory infiltrating cells in endomyocardial biopsy (EMB) samples during the 6-month follow-up, and to define predictors of LV function improvement among baseline parameters. Forty patients with biopsy-proven myocarditis and impaired LV function (LV ejection fraction-LVEF <40 %) with heart failure symptoms ≤ 6 months were evaluated. Myocarditis was defined as the presence of >14 mononuclear leukocytes/mm(2) and/or >7 T-lymphocytes/mm(2) in the baseline EMB. The EMB, echocardiography and clinical evaluation were repeated after 6 months of standard heart failure therapy. LVEF improved on average from 25 ± 9 to 42 ± 12 % (p < 0.001); LV end-systolic volume and LV end-diastolic volume (LVEDV) decreased from 158 ± 61 to 111 ± 58 ml and from 211 ± 69 to 178 ± 63 ml (both p < 0.001). NYHA class decreased from 2.6 ± 0.5 to 1.6 ± 0.6 (p < 0.001) and NTproBNP from 2892 ± 3227 to 851 ± 1835 µg/ml (p < 0.001). A decrease in the number of infiltrating leukocytes (CD45+/LCA+) from 23 ± 15 to 13 ± 8 cells/mm(2) and in the number of infiltrating T lymphocytes (CD3+) from 7 ± 5 to 4 ± 3 cells/mm(2) (both p < 0.001) was observed. The decline in the number of infiltrating CD45+ cells significantly correlated with the change in LVEF (R = -0.43; p = 0.006), LVEDV (R = 0.39; p = 0.012), NYHA classification (R = 0.35; p = 0.025), and NTproBNP (R = 0.33; p = 0.045). The decrease in the number of CD3+ cells correlated with the change of systolic and diastolic diameters of the left ventricle (R = -0.33; p = 0.038 and R = -0.45; p = 0.003) and with the change in LVEDV (R = -0.43; p = 0.006). Tricuspid annular plane systolic excursion (TAPSE) (OR 0.61; p = 0.005) and early transmitral diastolic flow velocity (E wave) (OR 0.89; p = 0.002) were identified as predictors of LVEF improvement. Improvements in clinical status, LV function and NTproBNP levels correlated with decrease in the number of infiltrating inflammatory cells. TAPSE and E wave velocity were significant predictors of improvement in multivariate regression. Our observations suggest that contemporary guidelines-based therapy of heart failure is an effective treatment option in patients with recent onset biopsy-proven inflammatory cardiomyopathy.
心肌炎和左心室（LV）功能障碍患者在接受标准心力衰竭治疗后可能会有所改善。这种改善似乎与心肌炎症的消退有关。本研究的目的是评估6个月随访期间临床、超声心动图和一些实验室参数的变化，并将它们与心内膜心肌活检（EMB）样本中炎性浸润细胞数量的变化相关联，同时确定基线参数中左心室功能改善的预测因素。对40例经活检证实为心肌炎且左心室功能受损（左心室射血分数-LVEF<40%）、心力衰竭症状≤6个月的患者进行了评估。心肌炎的定义为基线EMB中单核白细胞>14个/mm²和/或T淋巴细胞>7个/mm²。在标准心力衰竭治疗6个月后重复进行EMB、超声心动图和临床评估。LVEF平均从25±9%提高到42±12%（p<0.001）；左心室收缩末期容积和左心室舒张末期容积（LVEDV）分别从158±61ml降至111±58ml以及从211±69ml降至178±63ml（均p<0.001）。纽约心脏协会（NYHA）分级从2.6±0.5降至1.6±0.6（p<0.001），N末端B型利钠肽原（NTproBNP）从2892±3227μg/ml降至851±1835μg/ml（p<0.001）。观察到浸润白细胞（CD45+/白细胞共同抗原+）数量从23±15个/mm²降至13±8个/mm²，浸润T淋巴细胞（CD3+）数量从7±5个/mm²降至4±3个/mm²（均p<0.001）。浸润CD45+细胞数量的下降与LVEF的变化（R=-0.43；p=0.006）、LVEDV的变化（R=0.39；p=0.012）、NYHA分级的变化（R=0.35；p=0.025）以及NTproBNP的变化（R=0.33；p=0.045）显著相关。CD3+细胞数量的下降与左心室收缩和舒张直径的变化（R=-0.33；p=0.038和R=-0.45；p=0.003）以及LVEDV的变化（R=-0.43；p=0.006）相关。三尖瓣环平面收缩期位移（TAPSE）（比值比0.61；p=0.005）和二尖瓣舒张早期血流速度（E波）（比值比0.89；p=0.002）被确定为LVEF改善的预测因素。临床状况、左心室功能和NTproBNP水平的改善与浸润炎性细胞数量的减少相关。在多因素回归中，TAPSE和E波速度是改善的显著预测因素。我们的观察结果表明，当代基于指南的心力衰竭治疗是近期发病、经活检证实的炎性心肌病患者的一种有效治疗选择。
