Role of Endomyocardial Biopsy and Aetiology-based Treatment in Patients With Inflammatory Heart Disease in Arrhythmic and Non-arrhythmic Clinical Presentations: an Integrated Approach for the Optimal Diagnostic and Therapeutic Management
Conditions: Myocarditis, Ventricular Arrythmia, Inflammatory Cardiomyopathy, Genetic Predisposition, Autoimmunity, Arrhythmia, Cardiomyopathies, Immunosuppression, Catheter Ablation
Sponsor: Scientific Institute San Raffaele

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
1 
 
STUDY PROTOCOL SUMMARY 
 ____________________________________________________________________________ 
TITLE 
Descriptive: Role of endomyocardial biopsy and aetiology-based treatment in patients with 
inflammatory heart disease in arrhythmic and non-arrhythmic clinical presentations: an 
integrated approach for the optimal diagnostic and therapeutic management. 
Code: MYOCAR 
Final protocol date: 20/02/2020 (V03 - Multicenter) 
____________________________________________________________________________ 
HEAD CENTER 
Department of Electrophysiology and Arrhythmology, San Raffaele Hospital, Milan, Italy. 
____________________________________________________________________________ 
INVESTIGATORS  
Principal Investigators: Giovanni Peretto, MD – Simone Sala, MD 
Promoter: Paolo Della Bella, MD, Head Department of Electrophysiology and 
Arrhythmology, San Raffaele Hospital, Milan, Italy 
_____________________________________________________________________________ 
BACKGROUND 
Myocarditis is a complex  inflammatory disease, usually occurring secondary to viral 
infections, autoimmune processes or toxic agents [1]. Clinical presentations are multiple, 
including chest-pain, heart failure and a broad spectrum of arrhythmias [1].  In turn, 
outcome is largely unpredictable, ranging from mild self-limiting disease, to chronic stage 
and progressive evolution towards dilated cardiomyopathy, to rapid adverse outcome in 
fulminant forms [1,2]. Subsequently, myocarditis is often underdiagnosed and 
undertreated [3], and optimal diagnostic and therapeutic strategies are still to be defined. 
____________________________________________________________________________ 
RATIONALE 
Our study aims at answering multiple questions about myocarditis, with special attention 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
2 
 
to its arrhythmic manifestations.  
1. Optimal diagnostic workflow is still to be defined. In fact, although endomyocardial 
biopsy (EMB) is still the diagnostic gold standard, especially for aetiology identification 
[1], it is an invasive technique. Furthermore, it may lack sensitivity because of sampling 
errors. By converse, modern imaging techniques – cardiac magnetic resonance (CMR) 
in particular – have been proposed as alternative or complementary diagnostic tool in 
inflammatory heart disease [4,5,6]. Other noninvasive diagnostic techniques, like 
delayed-enhanced CT (DECT) scan or position emission tomography (PET) scan, are 
under investigation. 
2. Biomarkers to identify myocarditis aetiology, predisposition, prognosis and response 
to treatment are still to be defined [1,3,5]. 
3. Arrhythmic myocarditis is largely underdiagnosed and uninvestigated. Importantly, 
myocarditis presenting with arrhythmias requires specific diagnostic, prognostic and 
therapeutic considerations [2]. At our hospital, which is an international referral center 
for ventricular arrhythmias management and ablation, a relevant number of patients 
with unexplained arrhythmias had myocarditis as underlying aetiology. Our experience 
may considerably improve knowledge and management of arrhythmic myocarditis. 
4. The role of CMR, as well as alternative nonivasive imaging techniques, in defining 
myocarditis healing is a relevant issue. In particular, optimal timing for follow-up 
diagnostic reassessment is still to be defined, in patients with myocarditis at different 
inflammatory stages, either with or without aetiology-dependent treatment [4,7]. 
5. Uniformly-designed studies are lacking, to compare myocarditis among different 
patient subgroups, differing by variables like: clinical presentations, myocarditis stage, 
associated cardiac or extra-cardiac diseases, aetiology-based treatment, associated 
arrhythmic manifestations, diagnostic workup, and devices or ablation treatment  
[8,9,10]. 
____________________________________________________________________________ 
 
AIMS 
Our study has multiple aims (full detail in Table 1). 
1. To compare EMB with nonivasive diagnostic techniques (CMR, DECT, PET scan, either 
alone or in association). 
2. To assess the role of  blood biomarkers for identification of aetiology, predisposition, 
prognosis, response to treatment, inflammatory activity, clinical presentation. 
3. To describe myocarditis presenting with arrhythmias, with special focus on ventricular 
arrhythmias at different myocarditis stages and in different clinical contexts. To validate 
and generalize our model for optimal diagnostic and therapeutical management of 
arrhythmias in myocarditis patients (given the role of our hospital as an international 
referral center for arrhythmias ablation and management). 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
3 
 
4. To evaluate the timing needed for myocarditis healing in different patients subgroups, 
as assessed by nonivasive imaging techniques (CMR, DECT, PET scan), either alone or 
in association. 
5. To compare patients subgroups of myocarditis, in terms of epidemiology, aetiology,  
prognosis, and diagnostic-therapeutical strategies. Among the others, the main study 
subgroups will be: 
A. Arrhythmic vs. non-arrhythmic myocarditis. 
B. Arrhythmic myocarditis subgroups. 
C. Non-arrhythmic myocarditis subrgoups (i.e.: fulminant, acute coronary 
syndrome-like, 
pericarditis-like, 
heart 
failure, 
nonischaemic 
dilated 
/hypokynetic cardiomyopathies of unknown aetiology…). 
D. Infectious vs. aoutoimmune vs. toxic myocarditis. 
E. Myocarditis treated by aetiology-based treatment vs. isolated  cardiac medical 
treatment. 
F. Myocarditis at different disease stages: acute, hyperacute, fulminant, chronic 
active, post-inflammatory, or active vs. previous vs. non-myocarditis. 
G. Myocarditis presenting as organ-specific diseases vs. in the context of a genetic 
disorder or systemic disease. 
H. Myocardits vs. peri-myocarditis/myo-pericarditis. 
I. Other analyses. 
 
____________________________________________________________________________ 
STUDY DESIGN 
Our study, previously designed as a single-center experience, is multicenter, observational 
and both retrospective and prospective. 
Retrospective phase includes all clinical data occurring before the index event 
(hospitalization or clinically suspected myocarditis) and myocarditis diagnosis. 
Prospective phase includes all data following index event and myocarditis diagnosis. 
 
Any adult patient with clinically suspected myocarditis, of any clinical presentation and any 
degree of severity, will be considered as suitable for study enrollment. 
Patients will undergo diagnostic and therapeutical strategies considered as clinically 
indicated in a patient-tailored manner, as suggested by international guidelines 
recommendations and best local clinical practice. Patients will be free of either accepting 
or refusing any diagnostic or therapeutical proposal. Whenever accepted, data will be 
simply collected and analyzed. 
 
Based on clinical presentation, patients will be divided into two groups, arrhthmic (group 
A) and non-arrhythmic (group NA, including any other clinical presentation). 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
4 
 
Independently of A/NA groups, all patients will undergo optimal diagnostic and 
therapeutic strategies, as summarized in panel A. In parallel, special diagnostic and 
therapeutical strategies will be performed in patients with arrhythmic presentation or 
evidence of arrhythmias, as shown in panel B. Proposed flowcharts (panels A and B) 
represent only an approximate algorithm. Exceptions can be made in single cases, based on 
clinical indications. 
 
Panel A – Diagnostic and therapeutical workup in all patients. 
Independently of groups (A/NA), all patients will undergo optimal diagnostic and 
therapeutical workup, guided by updated scientific evidence merged with the clinical 
experience of the center. 
Baseline diagnostic workup will include: complete blood exams, 12-leads ECG, continuous 
telemetric monitoring, transthoracic doppler echocardiogram, coronary artery imaging 
(coronary angiography or CT scan). Any other clinically relevant diagnostic test will be 
collected. 
In life-threatening presentations (cardiogenic shock or malignant arrhythmias), support 
treatment by optimal medical therapy, inotropic or mechanical circulatory support, and 
acute-phase arrhythmia management (including cardioversion, defibrillation, or 
temporary pacing) will be performed, as indicated, before completing diagnostic workup.  
Final diagnosis of myocarditis will include, whenever applicable:  
A. For stable patients: 1) a second-level imaging technique (CMR as first choice; and/or 
DECT, PET, or multiple/fusion imaging techniques, based on clinical indications); 
followed by: 2) EMB, whenever clinically indicated. Blood exams for aetiology 
screening will be personalized upon clinical indications. 
B. For unstable patients: EMB only, as recommended. Blood exams for aetiology 
screening will be personalized upon clinical indications. 
Diagnostic criteria for myocarditis, as assessed by any diagnostic technique, will be defined 
based on international scientific evidence and will be constantly updated. Similar 
considerations apply to myocarditis staging and aetiology definition. Whenever not 
available at local institutions, diagnostic exams can be performed and analyzed at external 
centers.  
All patients with myocarditis (or any alternative final diagnosis), will undergo standard 
cardiological optimal medical treatment (COMT), as indicated. By converse, aetiology-
dependent treatment will be performed only in patients with a final diagnosis of any active 
(acute, fulminant, chronic active) myocarditis of defined aetiology (EMB-proved). 
Multidisciplinary assessment, including infective disease specialists (in viral/infective 
myocarditis), immunologists (in non-infective/autoimmune myocarditis) or any other 
specialist as needed, will be used to identify indications to treatment, drug choice (either 
approved or with a justified off-lable indication), treatment duration and safety profile, 
aiming at the best patients’ interest. Toxic myocarditis will be treated accordingly, by 
evaluating the opportunity of withdrawing pathogenic noxa.  
This protocol will not interfere with local best clinical practice. 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
5 
 
Patients with non-active myocarditis (previous or healed) or with non-myocarditis, will 
undergo “standard FU” (see below). Patients with active myocarditis will undergo 
“intensive FU” (see below). 
Independently of FU modalities, diagnostic reassessment will be considered in the 
presence of at least one of the following instability criteria: a) new unexplained cardiac 
symptoms (dypnoea, chest pain, syncope, palpitation); b) new unexplained increase in 
troponin or natriuretic peptides; c) new imaging abnormal signs; d) new unexplained 
clinically relevant arrhythmias. Diagnostic reassessment will include second-level imaging 
and/or EMB, as shown above. Subsequent therapeutical workup will be in line with the 
above explanations. In stable patients or undergone myocarditis healing, exercise stress 
test will be obtained, whenever possible. 
 
Panel B – Diagnostic and therapeutical workup of patients with arrhythmias 
In parallel with (and independently of) Panel A content, patients with arrhythmias (group 
A) will undergo specific diagnostic and therapeutical management for arrhythmias, as a 
result of the integration between international guidelines recommendations and the 
experience of a third-level center international referral center (San Raffaele Hospital, 
Milan) for arrhythmia management and ablation. 
To oversimplify, 4 groups of patients will be considered. 
1. Group 1: major ventricular arrhythmias (haemodynamically unstable VT, hu-VT; 
ventricular fibrillation, VF).   
After electrical stabilization and support treatment (panel A), indication to secondary 
prevention ICD implant will be multiparametric and patient-tailored. In patients with 
active myocarditis, subcutaneous ICD (S-ICD) or wearable CD (WCD) will be 
considered. Antiarrhythmic drugs will be considered in all Group 1 patients.  In 
addition, all Group 1 patients will undergo COMT and aetiology-dependent treatment 
whenever applicable (panel A). Ablation of ventricular arrhythmias will be considered 
in patients with severe arrhythmic presentation, or symptomatic, or refractory to 
optimal medical treatment. Electrophysiological study (EPS) may be used in selected 
cases. A CRT-D will replace ICD whenever indicated. 
2. Group 2: other ventricular arrhythmias (high-burden premature ventricular 
complexes = hb-PVC; nonsustained VT = NSVT; haemodynamically stable VT = hs-VT).  
Whenever clinically indicated, Group 2 patients will undergo invasive EPS (or in 
alternative nonivasive programmed ventricular stimulation in ICD carriers) to stratify 
arrhythmic risk. Patients with positive EPS will undergo ICD (or S-ICD/WCD) as in 
Group 1. Patients with negative EPS, as well as Group 2 cases not undergoing EPS, will 
undergo watchful waiting strategy (always with an intensive FU) with or without loop 
recorder implant: in these cases, ICD (or S-ICD/WCD) will be implanted only following 
documentation of relevant VA in FU. In addition, all Group 2 patients will undergo 
antiarrhythmic treatment, COMT and aetiology-dependent treatment whenever 
applicable (panel A). In symptomatic or drug-refractory cases, ablation of ventricular 
arrhythmias will be considered. A CRT-D will replace ICD whenever indicated. 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
6 
 
3. Group 3: bradyarrhythmias (2nd type II or 3rd degree atrioventricular block = 
advanced AVB; critical sinus pauses = SND).   
After electrical stabilization and support treatment (panel A), including the use of 
temporary pacemaker as a bridge-to-decision, patients will undergo watchful waiting 
strategy or definitive device implant. Instead of a pacemaker (PM), ICD will be 
considered in the presence of high-risk criteria for ventricular tachyarrhythmias, 
including: a) overlap with Group 1 presentation; b) overlap with Group 2 presentation, 
especially in the presence of positive EPS; c) other indications for primary prevention 
ICD implant (severe systolic dysfunction); d) signs of increased tachyarrhythmic risk 
(scar signs); e) patients with special aetiologies leading to an increased 
tachyarrhytmic risk (es: cardiac sarcoid, giant cell myocarditis, Chagas disease, 
overlapping genetic syndromes). In addition, all Group 3 patients will undergo COMT 
and aetiology-dependent treatment whenever applicable (panel A). A CRT-D or a CRT-
P will replace ICD or PM, respectively, whenever indicated. 
4. Group 4: supraventricular arrhythmias (atrial fibrillation = AF; atrial flutter = AFlu; 
atrial tachycardia = AT).  
Following acute-phase rate control (RaC), stable rhythm control (RyC) strategy will be 
considered as the therapeutical target, together with appropriate anticoagulation, as 
needed. Normal sinus rhythm will be obtained through either electrical or 
pharmacological cardioversion. In patients with unsuccessful attempts of sinus 
rhythm conversion, optimal treatment of active myocarditis will be considered as a 
primary target. Following myocarditis healing, in the presence of persistent 
arrhythmias, patients will be considered for RyC via electrical or pharmacological 
cardioversion. Transcatheter ablation will be an option for patients with drug-
symptomatic, recurrent or refractory arrhythmias. Permanent RaC strategy will be 
considered only in non responders. Widespread use of implantable loop recorders will 
apply, as clinically indicated. In addition, all Group 4 patients will undergo COMT and 
aetiology-dependent treatment whenever applicable (panel A). 
 
___________________________________________________________________________ 
STUDY POPULATION 
 
We will enroll adult patients (age ≥ 18 y), of any gender or ethnic group, evaulated for 
clinically suspected myocarditis. Patients can be enrolled from any medical environment 
or department, including inpatients, outpatients, and patients transferred from other 
hospitals. The same inclusion criteria will apply to the multicenter study (see below). 
___________________________________________________________________________ 
INCLUSION CRITERIA 
• Written informed consent.  
• Age ≥ 18 years. 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
7 
 
• Clinically suspected myocarditis [1]. 
• Enrollment performed by one of the participating Centers. 
____________________________________________________________________________ 
EXCLUSION CRITERIA 
• Absence of written informed consent. 
• Age < 18 years (paediatric population). 
___________________________________________________________________________ 
VARIABLES AND ENDPOINTS 
 
The main study variables are reported in Table 1 and in CRF. 
Endpoints will include: 
 Major endpoints: death; cardiac death; malignant ventricular arrhythmias ( = VT, VF, 
appropriate ICD therapy); heart transplantation; end-stage heart failure. 
 Minor endpoints: minor arrhythmias (NSVT; supraventricular arrhythmias; 
bradyarrhythmias); structural or functional myocardial abnormalities (any chamber 
dilation, systolic or diastolic dysfunction, including strain analysis, pericardial, 
vascular or valvular involvement, any other detectable abnormalities); abnormalities 
detectable by advanced imaging techniques (Lake Louise criteria and T-mapping 
techniques at CMR; any qualitative or quantitative imaging abnormality detectable by 
CMR, DECT or PET scan, or other imaging techniques, alone or in association); clinical 
variables (signs and symptoms related to cardiac or multisystemic disease; 
identification of associated diseases); blood exams abnormalities (inflammatory 
indexes; cardiac injury, inflammation or stress biomarkers; cardiac and extracardiac 
autoantibodies; genetic tests; tissue/organ damage indexes; markers of treatment 
toxicity; others); anatomical or functional abnormalities of coronary macro or 
microvascular structures (coronary angiography; CT scan; histology; provocative 
stress tests, nuclear medicine techniques); necessity of invasive elctrophysiological 
techniques (electrophysiological study; arrhythmia ablation; device implant) and 
related findings; indications and timing for primary and secondary prevention device 
implant, in relation with different therapeutic strategies; myocarditis recurrences; 
response to general and specific treatement; multiparametric modeling of prognostic 
risk 
stratification and 
response 
to treatment 
prediction; 
elaboration 
of 
multidisciplinary workup models. 
The main pimary and secondary variables are reported in detail in Table 1. 
 
Tabella 1 
 
N  
Aim 
N 
patients 
Primary Variables 
Secondary variables 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
8 
 
1 
Comparison between EMB 
and second level imaging 
findings 
1000 
• 
Diagnostic 
concordance 
• 
Inflammatory activity (presence; type; 
quantification) 
• 
Fibrosis (presence; type; quantification) 
• 
Coronary microvascular disease 
• 
Comparison between EMB sampling site and 
abnormal substrate localization at imaging 
(including substrate-guided EMB or alternative 
biopsy techniques) 
• 
Role of EMB guided by electroanatomical map 
• 
Diagnostic performance of DECT and/or PET, 
especially when CMR is contraindicated 
• 
Comparison between CMR/DECT findings and 
PET scan (including fusion imaging) or 
advanced imaging techniques including strain 
analysis at echocardiogram 
• 
Comparison between substrate abnormalities 
localizations (as assessed by second level 
imaging techniques) and arrhythmias (type, 
characteristics and origin site) 
• 
Comparison among different diagnostic 
techniques (EMB, CMR/DECT, PET) in terms of 
safety and diagnostic accuracy 
• 
Evaluation of differential diagnosis with other 
cardias diseases, and particulary with 
arrhythmogenic cardiomyopathy of any 
localization (left, right, biventricular, to identify 
updated diagnostic criteria) 
• 
Comparison between information provided by 
all the techniques above, and data from 
electroanatomical mapping (EAM) 
• 
Other analyses 
2 
Evaluation of blood exams 
and biomarkers 
 
1000 
• 
Identification of 
diagnostic 
biomkarkers 
• 
Identification of 
aetiology 
biomarkers  
• 
Cardiac and inflammatory biomarkers 
evaluation in different myocarditis subtypes 
• 
Identification of biomarkers of inflammatory 
stage (acute vs. chronic; active vs. previous) 
• 
Comparison between local and 
systemic/peripheral inflammation 
• 
Correlations with EMB and second-level 
imaging (CMR, DECT, PET…) findings 
• 
Identification of genetic factors with any role in 
predisposition, prognosis, response to 
treatment, or any other correlation, either in 
the presence or in the absence of underlying 
cardiomyopathy or autoimmune/inflammatory 
disease 
• 
Identification of prognostic biomarkers 
• 
Identification of biomarkers associated with 
treatment response 
• 
Evaluation of any tissue/organ damage or 
associated comorbidities 
• 
Study of cardiac autoantibodies 
• 
Study of any cell, tissue, genetic or circulating 
biomarker 
• 
Correlations with clinical presentations 
• 
Other analyses 
3 
Validation of optimal 
management of 
arrhythmic myocarditis 
1000 
• 
Evaluation of 
effects on major 
endpoints 
• 
Evaluation of effects on minor endpoints 
• 
Role of electrophysiological study in risk 
stratification 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
9 
 
(either in patients 
presenting with 
arrhythmias, or in those 
with evidence or 
arrhythmias during FU) 
• 
Role of loop recorders in arrhythmia 
monitoring 
• 
Role of transcatheter ablation (any technique) 
on arrhythmic outcomes 
• 
Identification of optimal timing for any 
electrophysiological/arrhythmologic procedure 
• 
Role of pharmacological antiarrhythmic 
treatment 
• 
Role of aetiology-specific treatment on 
arrhythmic outcomes 
• 
Identification of criteria for device implants 
(PM, ICD, S-ICD, CRT-D…) in myocarditis 
patients 
• 
Validation of therapeutic strategies and their 
optimal timing  in patients with 
supraventricular arrhythmias, 
bradyarrhythmias, or ventricular arrhythmias 
• 
Correlation between arrhytmia type/features 
with any other diagnostic exam performed at 
baseline or during FU (mainly EMB, 
CMR/DECT/PET, echocardiogram, stress tests, 
blood exams, genetic/blood/tissue/cell 
biomarkers) 
• 
Indications and timing for device (ICD, CRT-D) 
implant in primary prevention, based on 
multiparametric risk assessment, and in 
relation to different general and aetiology-
dependent treatments 
• 
Other analyses 
4 
Evaluation of healing 
timing in myocarditis 
500 
• 
Any degree of 
recovery by 3, 6, 9, 
12 and > 12 months 
 
• 
Comparison of healing times in treated vs. 
untreated patients 
• 
Correlations between healing times and clinical 
presentation types 
• 
Correlations between healing times and any 
biomarker 
• 
Correlations between healing times and any 
outcomes 
• 
Validation of exercise stress test role after 
myocarditis healing 
• 
Evaluation of PET scan or other diagnostic 
techniques as alternatives to CMR in special 
populations 
• 
Other analyses 
5 
Subrgoup analyses 
A. 
A vs. NA groups 
B. 
A myocarditis 
subgroups 
C. 
NA myocarditis 
subgroups (including 
fulminant) 
D. 
Infective vs. 
autoimmune vs. toxic 
forms 
E. 
Tretaed by aetiology-
driven therapy vs. 
standard 
cardiological 
treatment 
500 
(hugely 
variable 
in each 
subanalys
is) 
• 
Differences in 
major outcomes 
• 
Differences in minor outcomes  
• 
Differences in any biomarker 
• 
Differences in any diagnostic exam 
• 
Differences in aetiology 
• 
Differences in predisposition 
• 
Differences in inflammatory activity 
• 
Differences in pericardial involvement 
• 
Differences in systemic involvement 
• 
Differences in arrhythmias types and features 
• 
Differences in clinical presentation 
• 
Differences in treatment response, including 
novel treatments  
• 
Validation of local aetiology/pathophysiology-
dependent treatments (group E) 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
10 
 
 
___________________________________________________________________________ 
FOLLOW-UP VARIABLES 
 
Any quantitative and qualitative parameters detectable by medical history, objetcive 
examination,  biomarkers, 12-leads ECG, signal averaged ECG, continuous telemonitoring 
(during nwe hospitalization or in device carriers), Holter ECG (at least 24-hours, possibly 
12-leads), color Doppler transthoracic echocardiogram, coronary angiography or CT scan, 
stress tests, CMR, DECT, PET scan (alone or in association/fusion), genetic tests, tilting test, 
electrophysiological study (either invasive or nonivasive), electroanatomical map, any 
other imaging or laboratory exam identified as clinically-relevant.  
 
___________________________________________________________________________ 
FOLLOW-UP TIMELINE 
 
A clinical time zero (t0) will be considered as the start point for FU. t0  indicates the timing 
of myocarditis diagnosis, as assessed by EMB (first choice) or by imaging techniques 
(secondo choice).  
FU calendar will be variable based on clinical indications. As a general line, intensive FU 
will be planned for the first two years (month 3, month 6, month 9, month 12, month 18, 
month 24). For patients needing a strict control for relevant clinical issues, minimal FU 
reassessment is set at 2 weeks timespan. In the absence of clinical issues, from month 24 
FU will be performed every 6-12 months up to the end of the study. 
___________________________________________________________________________ 
FOLLOW-UP EXAMS 
 
• Standard FU: cardiological (or multidiciplinary) assessment 1-2/y with blood exams (at 
least troponin, natriuretic peptides, and inflammatory indexes), 12-leads ECG, Holter 
ECG monitoring, device interrogation (in device carriers), and color Doppler 
transthoracic echocardiogram. Second-level imaging techniques (CMR, DECT, PET scan) 
or other exams will be performed based on clinical indications. 
• Intensive FU: cardiological (or multidiciplinary) assessment 1-2/y with blood exams (at 
least troponin, natriuretic peptides, and inflammatory indexes), 12-leads ECG, Holter 
F. 
Different myocarditis 
stages and 
differential diagnoses 
G. 
Isolated vs. in the 
context o a systemic 
disease or genetic 
disease 
H. 
Myocarditis vs. 
perimyocardis/ 
myopericarditis 
• 
Validation of biomarkers and imaging 
techniques in monitoring response to treatment 
(group E) 
• 
Identification of optimal follow-up timeline 
• 
Other analyses 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
11 
 
ECG monitoring, device interrogation (in device carriers), and color Doppler 
transthoracic echocardiogram. Minimal reassessment timespan is 2 weeks. At least one 
second-level imaging techniques (CMR, DECT, PET scan) will be performed by 12 
months (approximately at 3, 6, 9, or 12 months based on clinical indications). Exercise 
stress test will be performed whenever clinically indicated, usually not before proved 
myocarditis healing. Other exams will be performed based on clinical indications. 
 
___________________________________________________________________________ 
STUDY DURATION 
Estimated study duration is 23 years (from Jaunary 2013 to December 2035). In detail: 
• Retrospective enrollment: from January 2013 to local institute review board approval. 
• Prospective enrollment: from local institute review board approval to Dicember 2025 
(estimated enrollment end). 
• FU duration per patient: 10 years. 
• Estimated last FU for last enrolled patient: December 2035. 
____________________________________________________________________________ 
CONFOUNDING FACTORS 
Not applicable. 
____________________________________________________________________________ 
EPIDEMIOLOGIC DATA 
Because of multiple clinical presentations and heterogeneous diagnostic techniques, 
myocarditis incidence is widely variable [1].  
At our institution, the mean rate of clinically suspected myocarditis is not inferior to 4 new 
cases/month. Epidemiology may be different at other centers. 
Target numbers reported in Table 1 are reasonable. 
 
____________________________________________________________________________ 
DATA COLLECTION AND STATISTICAL ANALYSIS  
 
Two enrollment modalities are accepted for this study: 1) prospective enrollment: at 
myocarditis diagnosis (following local institute review board approval); 2) retrospective 
enrollment: during FU of myocarditis patients (diagnosed before local institute review 
board approval).  
 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
12 
 
Considering incidence rate, local and general epidemiology, enrollment of 1000 
myocarditis cases by December 20205 is expected, including retrospective and prospective 
enrollment. For aim 1, 95% confidence intervals of 81-89% and of 75-85% are estimated 
for EMB and CMR, with 85% and 80% sensitivity, respectively. These data are consistent 
with updated knowledge. EMB will be considered as the diagnostic gold standard, as 
indicated [1]. 
Both baseline and FU data will be collected for each enrolled patient. CRF form reports the 
main study variables, in the form of an Excel document. 
 
Statistical analyses will be performed by certified programs (i.e. SPSS). 
 
Data will be presented as mean/median and standard deviation/interquartile range, or as 
contingency tables, depending on variables type and distribution. Parametric and non-
parametric tests will be used accordingly. Confidence intervals will be set at 95%. 
Statistical significance threshold will be set at p < 0.05. Regression models will be used for 
univariable and multivariable risk stratification and survival analyses. 
Either in all patients or in subgroups, appropriate statistical tests will be used for general 
and specific analyses, as needed to address each study aim (Table 1). 
 
____________________________________________________________________________ 
 
ETHICAL ISSUES 
 
Our study will be performed in accordance with Helsinki Declaration and current laws 
regarding observational prospective and retrospective studies. 
Diagnostic and therapeutical workup will not differ from daily clinical practice a tour 
hospital, as the result of updated international scientific evidence, integrated by the 
experience of a referral center for myocarditis and arrhythmias management, aiming at the 
best patients’ interest. Follow-up timeline and diagnostic exams will be required as 
clinically needed. No randomization procedures will be performed. Patient grouping will 
be “spontaneous”, based on clinical features and personalized overall workup. This study 
will respect the autonomy principle for any patient. At any time, patients will be free to 
accept or refuse any diagnostic or therapeutical proposal. As in daily clinical practice, 
critical or exceptional diagnostic and therapeutical options will be discussed in a 
multisiciplinary team and shared with patients, as needed. Per protocol, data will be simply 
collected and analyzed, without interfering with the best clinical practice. Thus, for any 
diagnostic exam or treatment, no special adverse reactions are expected, as compared to 
what observed in daily clinical practice. 
Written informed consent will be obtained for any enrolled patient. No physical or psycho-
social risks are expected regarding study procedures, informed consent, or authorization 
to use personal data.  
Institutional review board evaluation is necessary to approve the present study protocol. 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
13 
 
All data will be made anonymous. Analyses results will be published in international 
medical journals with impact factors. 
____________________________________________________________________________ 
 
REFERENCES 
 
1. Current state of knowledge on aetiology, diagnosis, management, and therapy 
of myocarditis: a position statement of the European Society of Cardiology Working 
Group on Myocardial and Pericardial Diseases. Caforio AL, Pankuweit S, Arbustini E, 
Basso C, Gimeno-Blanes J, Felix SB, Fu M, Heliö T, Heymans S, Jahns R, Klingel K, Linhart 
A, Maisch B, McKenna W, Mogensen J, Pinto YM, Ristic A, Schultheiss HP, Seggewiss H, 
Tavazzi L, Thiene G, Yilmaz A, Charron P, Elliott PM; European Society of Cardiology 
Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 
Sep;34(33):2636-48, 2648a-2648d. doi: 10.1093/eurheartj/eht210. Epub 2013 Jul 3. 
PMID: 23824828.  
2. 2015 European Society of Cardiology Guidelines for the management of patients with 
ventricular arrhythmias and the prevention of sudden cardiac death summarized by co-
chairs. Priori SG, Blomström-Lundqvist C. Eur Heart J. 2015 Nov 1;36(41):2757-9. doi: 
10.1093/eurheartj/ehv445. 
3. Update on myocarditis. Kindermann I, Barth C, Mahfoud F, Ukena C, Lenski M, Yilmaz A, 
Klingel K, Kandolf R, Sechtem U, Cooper LT, Böhm M. J Am Coll Cardiol. 2012 Feb 
28;59(9):779-92. doi: 10.1016/j.jacc.2011.09.074. Review. PMID: 22361396. 
4. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. Friedrich MG, 
Sechtem U, Schulz-Menger J, Holmvang G, Alakija P, Cooper LT, White JA, Abdel-Aty H, 
Gutberlet M, Prasad S, Aletras A, Laissy JP, Paterson I, Filipchuk NG, Kumar A, 
Pauschinger M, Liu P; International Consensus Group on Cardiovascular Magnetic 
Resonance in Myocarditis. J Am Coll Cardiol. 2009 Apr 28;53(17):1475-87. doi: 
10.1016/j.jacc.2009.02.007. PMID: 19389557. 
5. Survival and Left Ventricular Function Changes in Fulminant Versus Nonfulminant 
Acute Myocarditis. Ammirati E, Cipriani M, Lilliu M, Sormani P, Varrenti M, Raineri C, 
Petrella D, Garascia A, Pedrotti P, Roghi A, Bonacina E, Moreo A, Bottiroli M, Gagliardone 
MP, Mondino M, Ghio S, Totaro R, Turazza FM, Russo CF, Oliva F, Camici PG, Frigerio M. 
Circulation. 2017 Aug 8;136(6):529-545. doi: 10.1161/CIRCULATIONAHA.117.026386. 
Epub 2017 Jun 2. PMID:28576783. 
6. Characterization of normal and scarred myocardium based on texture analysis of 
cardiac computed tomography images. Antunes S, Esposito A, Palmisanov A, Colantoni 
C, de Cobelli F, Del Maschio A. Conf Proc IEEE Eng Med Biol Soc. 2016 Aug;2016:4161-
4164. doi: 10.1109/EMBC.2016.7591643. PMID:28269199. 
7. Quantitative changes in late gadolinium enhancement at cardiac magnetic resonance in 
the early phase of acute myocarditis. Ammirati E, Moroni F, Sormani P, Peritore A, 
Milazzo A, Quattrocchi G, Cipriani M, Oliva F, Giannattasio C, Frigerio M, Roghi A, Camici 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
14 
 
PG, 
Pedrotti 
P. 
Int 
J 
Cardiol. 
2017 
Mar 
15;231:216-221. 
doi: 
10.1016/j.ijcard.2016.11.282. Epub 2016 Nov 23. PMID:27913009. 
8. Clin Res Cardiol. 2016 Sep;105(9):763-73. doi: 10.1007/s00392-016-0986-9. Epub 
2016 Apr 25. Betaferon in chronic viral cardiomyopathy (BICC) trial: Effects of 
interferon-β treatment in patients with chronic viral cardiomyopathy. Schultheiss 
HP1,2, Piper C3, Sowade O4, Waagstein F5, Kapp JF4, Wegscheider K6, Groetzbach 
G4, Pauschinger M7,8, Escher F7,9, Arbustini E10, Siedentop H4, Kuehl U7,9. 
9. A 
clinical 
trial 
of 
immunosuppressive 
therapy 
for myocarditis. 
The Myocarditis Treatment Trial Investigators. Mason JW, O'Connell JB, Herskowitz A, 
Rose NR, McManus BM, Billingham ME, Moon TE. N Engl J Med. 1995 Aug 3;333(5):269-
75. PMID:7596370. 
10. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-
negative inflammatory cardiomyopathy: the TIMIC study. Frustaci A, Russo MA, 
Chimenti C. Eur Heart J. 2009 Aug;30(16):1995-2002. doi: 10.1093/eurheartj/ehp249. 
Epub 2009 Jun 25. PMID: 19556262. 
 
 
____________________________________________________________________________ 
 
 
Principal Investigators: Giovanni Peretto, MD - Simone Sala, MD 
 
 
____________________________________________________________________________ 
 
 
 
                                                             Appendix – Abbreviation List 
 
 
A = arrhythmic 
AAD = anti-arrhythmic drugs 
AF = atrial fibrillation 
AFlu = atrial flutter 
AT = atrial tachycardia 
AVB = atrioventricular block 
BE = blood exams 
BtD = bridge to decision 
CMR = cardiac magnetic resonance 
COMT = caridiologic optimal medical therapy 
CRT = cardiac resynchronization therapy (with ICD function=CRT-D; or without=CRT-
P) 
DECT = delayed-enhanced computed tomography 

MYOCAR - Version V03 - Multicenter 
Principal Investigators:  Giovanni Peretto, MD - Simone Sala, MD 
 
15 
 
EMB = endomyocardial biopsy 
EPS = electrophysiological study 
EST = exercise stress test 
FU = follow-up 
hb-PVC = high-burden premature ventricular complexes 
hs-VT = haemodinamically stable ventricular tachycardia 
hu-VT = haemodinamically unstable ventricular tachycardia 
ICD = implantable cardioverter defibrillator 
IST = immunosuppressive therapy 
LTC = life-threatening condition 
MCS = mechanical circulatory support 
NA = non-arrhythmic 
NR = non responder 
OMT = optimal medical therapy 
PM = pacemaker 
RaC = rate control strategy 
RyC = rhythm control strategy 
S-ICD = subcutaneous implantable cardioverter defibrillator 
SMT = special medical therapy 
SND = sinus node disease 
TCA = transcatheter ablation 
TTDE = transthoracic doppler echocardiogram 
VF = ventricular fibrillation 
VT = ventricular tachycardia 
WCD = life vest (wearable cardioverter defibrillator) 
ww = sorverglianza attiva (watchful waiting)