Intravenously administered immunoglobulins (IVIG) in high doses are indicated in patients with different immune system disorders. Their effect lies in the modulation of the immune system including inactivation of autoantibodies [99]. The favorable effect of IVIG on the heart function and prognosis was proved in patients with chronic heart failure [141], DCMP with the high viral load of PVB19 [142] and in children [143, 144] with the fulminant course of myocarditis and ICMP [147, 148]. In patients with chronic heart failure, in which higher activity of the immune system was described in previous studies, the study from 2001 proved anti-inflammatory effect of IVIG within the meaning of the decrease of pro-inflammatory cytokines like IL-1beta and by contrast of increasing the levels of anti-inflammatory cytokines (IL-10 and others) whose levels moreover correlated with the left ventricular ejection fraction [141]. Generally, the therapy led to the improvement of patients´ state of health including the decrease of plasmatic levels of NT-pro ANP.

The favorable effect of IVIG in recently developed DCMP and myocarditis in adults was described even in work from 1997 [145] when the improvement of left ventricular EF from 24 on 41 % generally was observed in patients. However, it was not a randomized study. On the other hand, a multicentric randomized study of the same author from 2001 with patients with new-onset DCMP in which an inflammatory infiltrate was present in 16 % of patients did not prove such effect in adults. Both placebo and IVIG group registered similar left ventricular EF improvement [146]. However, in the case of this study, there was marked as a limitation that just a small part of patients has histopathological evidence of an inflammation and that immunochemical analysis of bioptically taken samples of the myocardium was not performed [146, 147]. In more recent retrospective studies, a favorable effect of IVIG was proved in adult patients with fulminant myocarditis or ICMP when in a study from 2008 [147] it led to the average improvement of the left ventricular EF by 30 %. However, it was a small study. Another study from 2014 [148] was also retrospective, but with a larger group of patients and results were compared with a control group. In the IVIG group, the therapy led to the improvement of the left ventricular EF and reduction of the development of arrhythmias. However, for the reason that an effect of IVIG was not proved clearly by large multicentric randomized studies, their routine use in the acute phase of the disease in adult patients is not recommended, because according to the references, other necessary multicentric randomized studies have not been performed yet [24]. However, it the same reference it is stated that “IVIG has no major side-effects,” what was proved by studies [141, 143, 144], “and may be used in myocarditis refractory to conventional heart failure therapy, both viral and autoimmune forms, particularly if autoantibody-mediated.” [24] Thus, therapy with IVIG still remains not quite clearly and convincingly proved by evidence in the literature.

However, in children and teenagers, in contrast to adults, the situation is the opposite. A positive influence on the heart function and 1-year-survival rate was proved in children receiving high doses of IVIG [144] and in indicated cases they are administered even in routine practice because they are connected with better course and prognosis of the disease and there is described even the effect that they could prevent the progress of myocarditis into chronic phase [102].

Authors of the opening picture: Database Center for Life Science -DBCLS

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References:

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99) KUCHYNKA, P. a et al. Myokarditida a zánětlivá kardiomyopatie. Kapitoly z kardiologie. 2013, 3(-), 87-91.

102) STARÁ, V. Nestrukturální srdeční onemocnění u dětí. Vox Pediatriae. 2006, 6(4), 26-32.

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