Key result
Myocardial biopsy increased the rate of definite myocarditis diagnosis from 13% to 55% (p < 0.0001) in patients with clinically suspected fulminant myocarditis unweanable from mechanical circulatory support.
Why the study?
Myocardial biopsy can cause significant morbidity and mortality, and its therapeutic consequences in patients with fulminant clinically suspected myocarditis unweanable from MCS remain unclear.
Does myocardial biopsy improve diagnostic yield and alter treatment in patients with clinically suspected fulminant myocarditis unweanable from mechanical circulatory support?
Cohort (n=47)
No
Does myocardial biopsy improve diagnostic yield and alter treatment in patients with clinically suspected fulminant myocarditis unweanable from mechanical circulatory support?
In patients with fulminant myocarditis on mechanical circulatory support, myocardial biopsy increases diagnostic certainty but has a low rate of therapeutic impact and a high risk of complications like tamponade.
Answers are grounded in this paper and cite their sources.
Myocardial biopsy should be weighed carefully given low therapeutic yield and high complications in MCS patients; leaves open its net benefit in fulminant myocarditis.
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.
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Marquet et al. (2023) conducted a cohort in Fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (n=47). Myocardial biopsy vs. Before biopsy results (noninvasive work-up) was evaluated on Proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results (p=<0.0001). Myocardial biopsy increased the rate of definite myocarditis diagnosis from 13% to 55% (p < 0.0001) in patients with clinically suspected fulminant myocarditis unweanable from mechanical circulatory support.
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