During the summer this year, I had the opportunity and honour to undergo an internship in the Cardoimmunology Centre of Cardiology Clinics of University Hospital Padua in Italy under the leadership of Professor Caforio. Her team belongs to the pioneers in the field of management of inflammatory heart diseases including myocarditis. It is one of the biggest centres in Italy and Europe, ensuring care for over 1000 patients with myocarditis. The members of this team have been so kind as to share their time for making few interviews with them about the topic of myocarditis. Below you may find an interview with Dr. Giordani, Research Fellow who dedicated his professional career to myocarditis and published many articles on this topic in prestigious international medical journals.
Dear Dr. Giordani, could you please share some information about your career?
I am currently working as a Research Fellow at the Padova University Hospital, which is located in Northern Italy and serves as a third-level referral center for almost all kinds of cardiovascular diseases in our region, ranging from congenital heart disease to end-stage heart failure with need to heart transplant referral. I completed both my University studies and Cardiology training in this hospital and I am currently having the opportunity to keep working in this center in the Cardioimmunology field. During my Cardiology training I especially focused on multi-modality cardiac imaging and clinical management of myocarditis and immune-mediated pericarditis patients, with the possibility of working together with an expert Immunologist.
You have published many articles about myocarditis, including its fulminant form. Could you please tell more details about this specific form of myocarditis?
Myocarditis is a heterogeneous disease, as it can present in many forms. Among those, fulminant presentation is the most dangerous. Despite a standardized definition of fulminant myocarditis does not exist, it is usually intended as a form of myocarditis presentation in which hemodynamic support in terms of inotropic drugs or mechanical circulatory devices (i.e., ECMO, Impella) is needed. Moreover, incessant ventricular arrhythmias (i.e. arrhythmic storm) can coexist, also in presence of preserved left ventricular systolic function. An important concept is that fulminant myocarditis, rather than being a distinct form of myocarditis, is instead a peculiar clinical presentation of the disease, carrying a worse prognosis, even long after the resolution of the acute phase of the disease.
How has the treatment of fulminant myocarditis changed in recent years?
Myocarditis treatment in general should be always tailored both on the disease’s characteristics (i.e. histological type, infectious or immune-mediated etiology) and the patients’ features (i.e. hemodynamic stability, comorbidities). The first description of a fulminant myocarditis case was performed at the beginning of the 1990s; since then, the disease management evolved from basic hemodynamic support to etiological treatment, essentially driven by the results of endomyocardial biopsy. When myocarditis presents in a fulminant form, it is mandatory to achieve a sample of myocardial tissue as soon as possible in order to confirm the diagnosis of myocarditis (since myocarditis can mimic many other cardiovascular diseases), to establish the type of inflammatory infiltrate (for example, eosinophilic myocarditis deserves a different treatment than giant cell myocarditis) and to detect any infectious agent in the myocardium (which is a contraindication to immunosuppression and orients towards the use of antimicrobial drugs).
What is the future of fulminant myocarditis management based on your opinion?
The future of myocarditis treatment relies in precision medicine and personalized protocols. Further research is needed to identify individualized prognostic markers, especially the predictors of response to immunosuppressive therapy and the predictors of myocarditis relapse. It is only recently that fulminant myocarditis has been identified as a marker of worse prognosis both in the short and long term, while in the past it was incorrectly believed that this myocarditis form had a paradoxically low rate of mortality after the resolution of the acute phase of the disease. This reflect the amount of work that still has to be done in order to ensure that all suspected myocarditis patients with severe hemodynamic presentation are offered the best diagnostic and therapeutic methods.
What would you like to communicate to the readers of myocarditis.eu?
Fulminant myocarditis is only one of the many different aspects that inflammatory cardiomyopathy can present. Cardioimmunology is a new frontier of medicine with lots of promising advances in the near future. I hope that this will lead to improvement in the patients’ conditions.
