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      Autonomic Nervous Function and Arrhythmias in Patients with Acute Viral Myocarditis during a 6-Month Follow-Up Period

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          Objective: It was our aim to study the outcome of autonomic nervous function (ANF), heart rate variability (HRV) and arrhythmias in patients with acute viral myocarditis in a 6-month follow-up period after the diagnosis. Methods: ANF was measured in patients with acute viral myocarditis 1, 3 and 6 months after the disease was diagnosed. HRV and arrhythmias were monitored by 24-hour electrocardiogram during the follow-up examination. Results: Ninety-six patients with acute viral myocarditis were enrolled in this study; 58% showed abnormal ANF tests, and the incidence was reduced to 17% after 6 months (p < 0.01). Time and frequency domain analyses of HRV were significantly reduced in the early stage of the disease and recovered after 6 months (p < 0.05). The incidence of arrhythmias in patients with abnormal ANF was significantly higher than in patients with normal ANF (p < 0.05). The incidence of arrhythmias in patients with abnormal ANF at 6 months was significantly lower than that at the first month (p < 0.05). Conclusions: There is a significant impairment of ANF and a higher incidence of arrhythmias in the early stage of acute myocarditis. ANF and HRV abnormalities are significantly improved, and the incidence of arrhythmia is significantly reduced after 6 months in patients with acute myocarditis.

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          Most cited references 15

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          Electrocardiography of myocarditis revisited: clinical and prognostic significance of electrocardiographic changes.

          To clarify the clinical and prognostic value of the ECG, an ECG review was undertaken in 45 consecutive patients with a histologic diagnosis of active myocarditis (29 men and boys and 16 women and girls; age, 36.8 +/- 15 years; idiopathic myocarditis, 39 cases). In patients (21) with symptoms of recent onset (less than or equal to 1 month) AV block and repolarization abnormalities were the prevailing ECG features at the time of admission, and a pseudoinfarction pattern (Q waves plus ST-segment elevation) frequently heralded a rapidly fatal course ("fulminant myocarditis"). Left atrial enlargement and atrial fibrillation, left ventricular hypertrophy and LBBB, which prevailed in patients who had symptoms for longer periods, corresponded to the most severe degree of left ventricular dysfunction during the initial hemodynamic and echocardiographic evaluation. The overall mortality rate after 58 +/- 24 months from the time of diagnosis was 29%. Abnormal QRS complexes and LBBB were markers of poor survival, independently of initial indexes of left and right ventricular function, both of which indicate an increased propensity for sudden cardiac death.
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            Focal atrial fibrillation: experimental evidence for a pathophysiologic role of the autonomic nervous system.

            Focal paroxysmal atrial fibrillation (AF) was shown recently to originate in the pulmonary veins (PVs) and superior vena cava (SVC). In the present study, we describe an animal model in which local high-frequency electrical stimulation produces focal atrial activation and AF/AT (atrial tachycardia) with electrogram characteristics consistent with clinical reports. In 21 mongrel dogs, local high-frequency electrical stimulation was performed by delivering trains of electrical stimuli (200 Hz, impulse duration 0.1 msec) to the PVs/SVC during atrial refractoriness. Atrial premature depolarizations (APDs), AT, and AF occurred with increasing high-frequency electrical stimulation voltage. APD/AT/AF originated adjacent to the site of high-frequency electrical stimulation and were inducible in 12 of 12 dogs in the SVC and in 8 of 9 dogs in the left superior PV (left inferior PV: 7/8, right superior PV: 6/8; right inferior PV: 4/8). In the PVs, APDs occurred at 13+/-8 V and AT/AF at 15+/-9 V (P < 0.01; n = 25). In the SVC, APDs were elicited at 19+/-6 V and AT/AF at 26+/-6 V (P < 0.01; n = 12). High-frequency electrical stimulation led to local refractory period shortening in the PVs. The response to high-frequency electrical stimulation was blunted or prevented after beta-receptor blockade and abolished by atropine. In vitro, high-frequency electrical stimulation induced a heterogeneous response, with shortening of the action potential in some cells (from 89+/-35 msec to 60+/-22 msec; P < 0.001; n = 7) but lengthening of the action potential and development of early afterdepolar-izations that triggered APD/AT in other cells. Action potential shortening was abolished by atropine. High-frequency electrical stimulation evokes rapid ectopic beats from the PV/SVC, which show variable degrees of conduction block to the atria and induce AF, resembling findings in patients with focal idiopathic paroxysmal AF. The occurrence of the arrhythmia in this animal model was likely due to alterations in local autonomic tone by high-frequency electrical stimulation. Further research is needed to prove absolutely that the observed effects of high-frequency electrical stimulation were caused by autonomic nerve stimulation.
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              Myocarditis and inflammatory cardiomyopathy: microbiological and molecular biological aspects.

              Myocarditis is an inflammatory disease of the myocardium associated with cardiac dysfunction. The natural history of myocarditis is frequently characterised by the evolution in dilated cardiomyopathy. Due to its variable clinical manifestation from latent to very severe clinical forms, such as acute congestive heart failure and sudden death, its prevalence is still unknown and probably underestimated. In spite of the development of various diagnostic modalities, early and definite diagnosis of myocarditis still depends on the detection of inflammatory infiltrates in endomyocardial biopsy specimens according to the Dallas criteria. Routine application of immunohistochemistry, used for identification and characterisation of inflammatory cell populations, has now significantly increased the sensistivity of the diagnosis of inflammatory cardiomyopathy. Various molecular techniques, such as PCR, gene sequencing and real-time PCR, often applied on the same endomyocardial specimen, have become an essential part of the diagnostic armamentarium for rapid, specific and sensitive identification of infective agents. The correct application of molecular techniques will allow increasingly more information to be obtained: new epidemiology, new patient risk stratification and overall more appropriate medical treatment.

                Author and article information

                S. Karger AG
                March 2009
                06 November 2008
                : 113
                : 1
                : 66-71
                Departments of aCardiology and bCardiac Surgery, Heart Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
                167794 Cardiology 2009;113:66–71
                © 2008 S. Karger AG, Basel

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                Page count
                Tables: 4, References: 29, Pages: 6
                Original Research


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