Endomyocardial biopsy: safety and prognostic utility in paediatric and adult myocarditis in the European Society of Cardiology EURObservational Research Programme Cardiomyopathy and Myocarditis Long-Term Registry
Authors: Caforio Alida L P , Kaski Juan P , Gimeno Juan R , Elliott Perry M , Laroche Cecile , Tavazzi Luigi , Tendera Michal , Fu Michael , Sala Simone , Seferovic Petar M , Heliö Tiina , Calò Leonardo , Blagova Olga , Amin Ahmad , Kindermann Ingrid , Sinagra Gianfranco , Frustaci Andrea , Bonnet Daniel , Charron Philippe , Maggioni Aldo P ,   CMY Registry Investigators, Ferrari R , Alonso A , Bax J , Blomström-Lundqvist C , Gielen S , Lancellotti P , Maggioni A P , Maniadakis N , Pinto F , Ruschitzka F , Tavazzi L , Vardas P , Weidinger F , Zeymer U , Vahanian A , Budaj A , Dagres N , Danchin N , Delgado V , Emberson J , Friberg O , Gale C P , Heyndrickx G , Iung B , James S , Kappetein A P , Maggioni A P , Maniadakis N , Nagy K V , Parati G , Petronio A-S , Pietila M , Prescott E , Ruschitzka F , Van de Werf F , Weidinger F , Zeymer U , Gale C P , Beleslin B , Budaj A , Chioncel O , Dagres N , Danchin N , Emberson J , Erlinge D , Glikson M , Gray A , Kayikcioglu M , Maggioni A P , Nagy K V , Nedoshivin A , Petronio A-P , Roos-Hesselink J W , Wallentin L , Zeymer U , Popescu B A , Adlam D , Caforio A L P , Capodanno D , Dweck M , Erlinge D , Glikson M , Hausleiter J , Iung B , Kayikcioglu M , Ludman P , Lund L , Maggioni A P , Matskeplishvili S , Meder B , Nagy K V , Nedoshivin A , Neglia D , Pasquet A A , Roos-Hesselink J W , Rossello F J , Shaheen S M , Torbica A , Caforio Alida , Gimeno Blanes Juan Ramon , Charron Philippe , Elliott Perry , Kaski Juan Pablo , Maggioni Aldo P , Tavazzi Luigi , Tendera Michal , Pihkala J , Ojala T , Hiippala A , Jarvinen T , Lommi J , Helio T , Sinisalo J , Bonnet D , Khraiche D , Szezepanski I , Charron P , Mankikian S , Maupain C , Collet J-P , Gandjbakhch E , Kerneis M , Pruny J-F , Bauer A , Pfeiffer B , Felix S B , Beug D , Dorr M , Kaczmarek S , Lehnert K , Pedersen A-L , Bruder M , Gorenflo M , Arnold R , Uhl S , Ziesenitz V , Jung A , Roesch E , Böhm M , Kindermann I , Linicus Y , Werner C , Neurath B , Schild-Ungerbuehler M , Kindermann M , Kaski J P , Norrish G , Field E , Elliott P , Lorenzini M , Watkinson O , Wicks E , Anastasakis A , Ritsatos K , Vlagkouli V , Rammos S , Kourelis G , Giannakopoulou A , Karanasios E , Papachristou P , Papadopoulos G , Servos G , Maleki M , Noohi Bezanjani F , Amin A , Naderi N , Parsaee M , Taghavi S , Ghadrdoost B , Jafari S , Khoshavi M , Della Bella P , Sala S , Peretto G , Calabro R , Pacileo G , Russo M G , Limongelli G , Esposito A , Gragnano F , Gravino R , Marrazzo T , Masarone D , Pazzanese V , Rubino M , Tramonte S , Valente F , Caiazza M , Calabro P , Cirillo A , Trimarco B , Losi M-A , Di Nardo C , Giamundo A , Pacelli F , Canciello G , Iliceto S , Caforio A , Calore C , Leoni L , Perazzolo Marra M , Rigato I , Tarantini G , Schiavo A , Testolina M , Fedele F , Frustaci A , Alfarano M , Chimenti C , Drago F , Baban A , Calò L , Lanzillo C , Martino A , Uguccioni M , Zachara E , Halasz G , Re F , Sinagra G , Carriere C , Merlo M , Ramani F , Kavoliuniene A , Krivickiene A , Tamuleviciute-Prasciene E , Viezelis M , Celutkiene J , Balkeviciene L , Laukyte M , Paleviciute E , Asselbergs F , De Jonge N , Kirkels J H , Van Der Heijden J , Van Laake L , Sammani A , Mizia-Stec K , Tendera M , Wybraniec M , Czekaj A , Sikora-Puz A , Skoczynska A , Rubis P , Wisniowska-Smialek S , Grzybowski J , Ojrzynska N , Bilinska Z , Chmielewski P , Foss-Nieradko B , Michalak E , Stepien-Wojno M , Mazek B , Brzezinska-Rajszys G , Ziolkowska L , Boruc A , Plodzien E , Rocha Lopes L , Almeida A R , Cruz I , Gomes A C , Pereira A R , Ginghina C , Jurcut R , Apetrei E , Militaru S , Mircea Coman I , Mursa A , Popescu B A , Frigy A , Fehervari L , Fogarasi Z , Kocsis I , Szabo I A , Nikitin I , Resnik E , Komissarova M , Lazarev V , Shebzukhova M , Ustyuzhanin D , Blagova O , Alieva I , Kulikova V , Lutokhina Y , Pavlenko E , Varionchik N , Zaklyazminskaya E , Dzemeshkevich S , Kolbasova E , Kotlukova N , Rusinova V , Ristic A D , Seferovic P M , Pavlovic A , Radovanovic G , Simeunovic D , Zivkovic I , Milinkovic I , Gran Ipina F , Roses Noguer F , Albert Brotons D , Cequier A , Salazar-Mendiguchia J , Gonzalez J , Manito N , Garcia-Pavia P , Briceno A , Cobo-Marcos M , Dominguez F , Gimeno Blanes J R , Castro F J , Munoz Esparza C , Sabater Molina M , Sorli García M , Lopez Cuenca D , Ripoll-Vera T , Alvarez J , Nunez J , Gomez Y , Sanchez Fernandez P L , Villacorta E , Avila C , Bravo L , Diaz-Pelaez E , Gallego-Delgado M , Garcia-Cuenllas L , Plata B , Fu M , Canpolat U 
Published: April 2024

Abstract

Background and Aims
Contemporary multicentre data on clinical and diagnostic spectrum and outcome in myocarditis are limited. Study aims were to describe baseline features, 1-year follow-up, and baseline predictors of outcome in clinically suspected or biopsy-proven myocarditis (2013 European Society of Cardiology criteria) in adult and paediatric patients from the EURObservational Research Programme Cardiomyopathy and Myocarditis Long-Term Registry.

Methods
Five hundred eighty-one (68.0% male) patients, 493 adults, median age 38 (27–52) years, and 88 children, aged 8 (3–13) years, were divided into 3 groups: Group 1 (n = 233), clinically suspected myocarditis with abnormal cardiac magnetic resonance; Group 2 (n = 222), biopsy-proven myocarditis; and Group 3 (n = 126) clinically suspected myocarditis with normal or inconclusive or no cardiac magnetic resonance. Baseline features were analysed overall, in adults vs. children, and among groups. One-year outcome events included death/heart transplantation, ventricular assist device (VAD) or implantable cardioverter defibrillator (ICD) implantation, and hospitalization for cardiac causes.

Results
Endomyocardial biopsy, mainly right ventricular, had a similarly low complication rate in children and adults (4.7% vs. 4.9%, P = NS), with no procedure-related death. A classical myocarditis pattern on cardiac magnetic resonance was found in 31.3% of children and in 57.9% of adults with biopsy-proven myocarditis (P &lt; .001). At 1-year follow-up, 11/410 patients (2.7%) died, 7 (1.7%) received a heart transplant, 3 underwent VAD (0.7%), and 16 (3.9%) underwent ICD implantation. Independent predictors at diagnosis of death or heart transplantation or hospitalization or VAD implantation or ICD implantation at 1-year follow-up were lower left ventricular ejection fraction and the need for immunosuppressants for new myocarditis diagnosis refractory to non–aetiology-driven therapy.

Conclusions
Endomyocardial biopsy was safe, and cardiac magnetic resonance using Lake Louise criteria was less sensitive, particularly in children. Virus-negative lymphocytic myocarditis was predominant both in children and adults, and use of immunosuppressive treatments was low. Lower left ventricular ejection fraction and the need for immunosuppressants at diagnosis were independent predictors of unfavourable outcome events at 1 year.