Pediatric Viral Myocarditis Treatment & Management
- Author: Edwin Rodriguez-Cruz, MD; Chief Editor: Howard S Weber, MD, FSCAI more...
In the acute phase of viral myocarditis, the patient should be admitted to the hospital, even if only mild signs of respiratory distress or congestive heart failure are present. Rapid progression to overt heart failure, hemodynamic collapse, or both may occur. Consultation with a cardiologist is indicated. Transfer to a facility with intensive and cardiology care may be required.
Medical care is aimed at minimizing the body’s hemodynamic demands. No specific proven therapy is available to prevent myocardial damage, but maintenance of tissue perfusion is the goal to avoid further complications. Normal arterial blood oxygen levels should be maintained with supplemental oxygen as needed.
Conventional management of viral myocarditis includes the use of digoxin, diuretics, and afterload reduction. Severe cases with hemodynamic compromise may require intravenous inotropic agents, afterload reduction, vasodilators, and anticoagulation. Discharge patients with viral myocarditis when they are stable on oral medications.
Extracorporeal membrane oxygenation (ECMO) has been used as an interim treatment to provide rest to the heart and as a bridge for transplant in selected patients with good results. Left ventricular assist devices may also be utilized in those patients with poor left ventricular function that does not recover and as a bridge to transplantation.
Diet and activity
A low-salt diet is recommended for patients with congestive heart failure. Bed rest is necessary during the acute phase of the illness and may slow the intramyocardial replication of the virus. Activity is permitted as partial or complete recovery is achieved. Restrict patient activity based on performance after the acute phase.
Monitor medication doses and adverse effects. Serial echocardiography is useful in monitoring ventricular function. Avoid negative inotropes. Be aware of the possibility of a further decrease in ventricular function.
Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs. 2002. 4(3):171-81. [Medline].
[Guideline] Aretz HT. Myocarditis: the Dallas criteria. Hum Pathol. 1987 Jun. 18(6):619-24. [Medline].
Fett JD. Diagnosis of viral cardiomyopathy by analysis of peripheral blood?. Expert Opin Ther Targets. 2008 Sep. 12(9):1073-5. [Medline].
Kühl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. 2005 Sep 27. 112(13):1965-70. [Medline].
Molina KM, Garcia X, Denfield SW, Fan Y, Morrow WR, Towbin JA, et al. Parvovirus B19 myocarditis causes significant morbidity and mortality in children. Pediatr Cardiol. 2013 Feb. 34(2):390-7. [Medline].
Kawashima H, Morichi S, Okumara A, Nakagawa S, Morishima T. National survey of pandemic influenza A (H1N1) 2009-associated encephalopathy in Japanese children. J Med Virol. 2012 Aug. 84(8):1151-6. [Medline].
Lerner AM, Wilson FM. Virus myocardiopathy. Prog Med Virol. 1973. DA - 19730608:63-91. [Medline].
Kindermann I, Kindermann M, Kandolf R, Klingel K, Bültmann B, Müller T, et al. Predictors of outcome in patients with suspected myocarditis. Circulation. 2008 Aug 5. 118(6):639-48. [Medline].
Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. 2008 Sep. 29(17):2073-82. [Medline]. [Full Text].
Bowles NE, Ni J, Kearney DL, et al. Detection of viruses in myocardial tissues by polymerase chain reaction. evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol. 2003 Aug 6. 42(3):466-72. [Medline].
Renko M, Leskinen M, Kontiokari T, et al. Cardiac troponin-I as a screening tool for myocarditis in children hospitalized for viral infection. Acta Paediatr. 2009 Nov 4. [Medline].
Sun Y, Ma P, Bax JJ, et al. 99mTc-MIBI myocardial perfusion imaging in myocarditis. Nucl Med Commun. 2003 Jul. 24(7):779-83. [Medline].
Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec. 120(6):1278-85. [Medline].
Aretz HT. Diagnosis of myocarditis by endomyocardial biopsy. Med Clin North Am. 1986 Nov. 70(6):1215-26. [Medline].
Mahfoud F, Gärtner B, Kindermann M, Ukena C, Gadomski K, Klingel K, et al. Virus serology in patients with suspected myocarditis: utility or futility?. Eur Heart J. 2011 Apr. 32(7):897-903. [Medline].
Weber MA, Ashworth MT, Risdon RA, Malone M, Burch M, Sebire NJ. Clinicopathological features of paediatric deaths due to myocarditis: an autopsy series. Arch Dis Child. 2008 Jul. 93(7):594-8. [Medline].
Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995 Aug 3. 333(5):269-75. [Medline].
Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation. 1994 Jan. 89(1):252-7. [Medline].
Robinson JL, Hartling L, Crumley E, et al. A systematic review of intravenous gamma globulin for therapy of acute myocarditis. BMC Cardiovasc Disord. 2005 Jun 2. 5(1):12. [Medline].