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Pediatric Nonviral Myocarditis Treatment & Management

  • Author: Stuart Berger, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Mar 30, 2015
 

Approach Considerations

Medical therapy for CHF is fairly standard.[7] The general principles of therapy for CHF are applicable to patients with myocarditis. These principles include the manipulation of preload, afterload, and contractility. Therefore, fluid restriction and diuretics, inotropic support to optimize contractility with continuous intravenous (IV) inotropic agents, and IV vasodilator agents, are all important potential interventions for CHF caused by myocarditis of a nonviral origin.

Additional general maneuvers to reduce the workload of the heart, thereby improving symptoms of CHF, include the following:

  • Inotropes via continuous drip
  • Afterload reducing agents
  • Diuretics
  • Digitalis
  • Beta-blockers
  • Mechanical ventilation
  • Arrhythmia therapy
  • Anticoagulation
  • Metabolic demand reduction
  • Bed rest

Treatment of the specific causes of the myocarditis (ie, bacterial sepsis, rickettsial disease) is necessary. However, it is still not entirely clear if the use of immunosuppressive therapy for myocarditis is indicated.

Some rationale for immunosuppressive therapy for myocarditis has been put forth, because the pathophysiology of myocarditis appears to involve the immune system's reaction against the myocardium. Adult studies have failed to clearly determine the role of immunosuppressive therapy. Some preliminary data suggest that certain combinations of immunosuppressive agents may be beneficial in patients with acute myocarditis.[8]

Surgical therapy

Surgical care for patient with myocarditis is primarily recommended if medical treatment fails and if the patient is symptomatic.

Surgical treatment may include cardiac transplantation for patients that develop a chronic, symptomatic dilated cardiomyopathy.

Pediatric ventricular assist devices (VADs) have been used as bridges to children with end-stage heart failure, including those resulting from myocarditis.[9]

Another surgical procedure that may be used is left ventricular volume reduction (Battista operation).

Inpatient care

Need for and length of inpatient care varies with severity of the illness. Prolonged supportive therapy may be required until the patient can resume spontaneous ventilation and be adequately maintained on oral anticongestive therapy.

Patient follow-up

Patients require close outpatient follow-up care, especially if significant residual CHF is present. Some patients may continue to have symptoms of moderate to severe CHF that may require eventual cardiac transplantation.

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Diet and Activity

Advise patients with chronic, moderate to severe CHF that a "no-added-salt" diet is probably beneficial. Otherwise, ensure adequate calories and nutrition for growth.

During the acute phase of myocarditis, most agree that bed rest should be recommended. Several animal studies have suggested that exercise during the acute viremia can potentiate the disease. However, after recovery and during the healing and/or chronic phases of myocarditis, activity as tolerated is believed to be acceptable.

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Contributor Information and Disclosures
Author

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Ameeta Martin, MD Clinical Associate Professor, Department of Pediatric Cardiology, University of Nebraska College of Medicine

Ameeta Martin, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Allen Towbin, MD, MSc FAAP, FACC, FAHA, Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, Texas Pediatric Society, Cardiac Electrophysiology Society

Disclosure: Nothing to disclose.

References
  1. Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis. 2010 Jan-Feb. 52(4):274-88. [Medline].

  2. Shamna RB, Lalitha AV, Lini B. Myocarditis in Children. Indian J Pediatr. 2013 Sep 26. [Medline].

  3. Libman E, Sacks B. A hitherto undescribed form of valvular and mural endocarditis. Arch Intern Med. 1974. 33:701-37.

  4. Klugman D, Berger JT, Sable CA, et al. Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol. 2010 Feb. 31(2):222-8. [Medline].

  5. Sachdeva S, Song X, Dham N, Heath DM, DeBiasi RL. Analysis of clinical parameters and cardiac magnetic resonance imaging as predictors of outcome in pediatric myocarditis. Am J Cardiol. 2015 Feb 15. 115(4):499-504. [Medline].

  6. Crossman DJ, Ruygrok PN, Hou YF, Soeller C. Next-generation endomyocardial biopsy: the potential of confocal and super-resolution microscopy. Heart Fail Rev. 2015 Mar. 20(2):203-14. [Medline].

  7. [Guideline] Heart Failure Society Of America. Myocarditis: Current treatment. J Card Fail. 2006 Feb. 12(1):e120-2. [Medline].

  8. Frustaci A, Pieroni M, Chimenti C. Immunosuppressive treatment of chronic non-viral myocarditis. Ernst Schering Res Found Workshop. 2006. 343-51. [Medline].

  9. Miller JR, Lancaster TS, Eghtesady P. Current approaches to device implantation in pediatric and congenital heart disease patients. Expert Rev Cardiovasc Ther. 2015 Apr. 13(4):417-27. [Medline].

 
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Myocarditis with scarring, autopsy. The image is a short axis gross photograph of an 8-year-old child with clinical myocarditis showing scarring of both ventricles, more prominent in the left. The fibrosis shows a random distribution with epicardial, myocardium, and pericardial involvements.
 
 
 
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