Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy.
Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracic Department, Institute of Pathological Anatomy and Histology, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy.
Eur J Heart Fail. 2021 Feb;23(2):211-216. doi: 10.1002/ejhf.1969. Epub 2020 Aug 20.
Latest statements from European and American societies recommend to rule out viral presence in endomyocardial biopsy (EMB) via polymerase chain reaction (PCR) analysis before starting immunosuppression or immunomodulation in acute lymphocytic myocarditis presenting with life-threatening scenarios. However, recommendations in myocarditis are mostly based on heterogeneous studies enrolling patients with inflammatory cardiomyopathies and established heart failure rather than acute myocarditis. Thus, definitive evidence of a survival benefit from immunomodulation guided by viral presence is currently lacking. Finally, distinguishing innocent bystanders from causative agents among EMB-detected viruses remain challenging and a major goal to achieve in the near future. Therefore, considerable divergence remains between official recommendations and clinical practice, including the possibility of starting immunosuppressive therapy empirically, without knowing viral PCR results. This review systematically discusses the unsolved issues of immunomodulation guided by viral presence in acute lymphocytic myocarditis, namely (i) virus epidemiology and prognosis, (ii) variability of viral presence rates, (iii) the role of potential viral bystander findings, and (iv) the main results of immunosuppression controlled trials in lymphocytic myocarditis. Furthermore, a practical approach for the critical use of viral presence analysis in guiding immunomodulation is provided, highlighting its importance before starting immunosuppression or immunomodulation. Future, multicentre studies are needed to address specific scenarios such as fulminant lymphocytic myocarditis and a virus-tailored management as for parvovirus B19.
最新的欧美学会声明建议，在开始免疫抑制或免疫调节治疗危及生命的急性淋巴细胞性心肌炎之前，通过聚合酶链反应（PCR）分析排除心肌活检（EMB）中的病毒存在。然而，心肌炎的推荐主要基于异质性研究，这些研究纳入了炎症性心肌病和已确诊心力衰竭的患者，而不是急性心肌炎患者。因此，目前缺乏病毒存在指导免疫调节的生存获益的明确证据。最后，区分心肌活检中检测到的病毒中的无辜旁观者和致病因素仍然具有挑战性，这是近期的主要目标。因此，官方建议和临床实践之间仍然存在相当大的分歧，包括在不知道病毒 PCR 结果的情况下，凭经验开始免疫抑制治疗的可能性。本综述系统地讨论了急性淋巴细胞性心肌炎中病毒存在指导免疫调节的未解决问题，即（i）病毒流行病学和预后，（ii）病毒存在率的可变性，（iii）潜在病毒旁观者发现的作用，以及（iv）淋巴细胞性心肌炎的免疫抑制对照试验的主要结果。此外，还提供了一种在指导免疫调节方面批判性使用病毒存在分析的实用方法，强调了在开始免疫抑制或免疫调节之前其重要性。未来需要开展多中心研究，以解决暴发性淋巴细胞性心肌炎和病毒靶向治疗等特定情况。
