Cardiovascular experts, Drs. JoAnn Lindenfeld, Javid Moslehi and Richa Gupta from Vanderbilt University Medical Center and Dr. Enrico Ammirati from Milan, Italy join Amit and Dan for a two part discussion about all things to consider for myocarditis in general (part 1) and myocarditis in the COVID era (part 2). Flutter Moment/Song by Drs. Matt (Internal Medicine) and Beth Faiman (Oncology).
- What is myocarditis?
- How do we classify it?
- How do we diagnose myocarditis?
- Why don’t we biopsy everyone?
- When do we think biopsy may change management?
- Do we really understand the mechanism of myocardial injury in what we call myocarditis?
- How do we figure mechanisms out and why is this important?
Cardiovascular experts, Drs. JoAnn Lindenfeld, Javid Moslehi and Richa Gupta from Vanderbilt University Medical Center and Dr. Enrico Ammirati from Milan, Italy join Amit and Dan for a two part discussion about all things to consider for myocarditis in general (part 1) and COVID-19 myocarditis and heart transplantation in the COVID-19 era (part 2). Flutter Moment by Barrie Stanton (RN).
The CardioNerds discuss a case of fulminant myocarditis, teaching a comprehensive approach to myocarditis with just 5 foundational principles. Review the myocarditis infographic on the myocarditis topic page. The episode ends with a special message from the true heroes of this episode, Chas and Julie Miller.
5 points of maximal impulse in approaching myocarditis
- Build the clinical suspicion for myocarditis: You need a high index of suspicion given the variable presentation, and definitely need to keep a differential so you don’t miss things like acute coronary syndromes.
- Decide if EMBx is necessary: Most often obtained in fulminant presentations to look for pathologic findings of giant cell myocarditis or eosinophilic myocarditis, because these findings will change management.
- Manage the acute cardiac injury, which can range from supportive care to treatment of shock, arrhythmias, and even tamponade.
- Manage the chronic cardiac sequelae: Recovering from the acute phase of myocarditis doesn’t necessarily mean smooth sailing — some develop chronic heart failure, warranting GDMT — or guideline directed management and therapy, as defined by Dr. Randall Starling in Ep 13.
- Treat the myocarditis: Immunosuppression is often started empirically in fulminant disease, but continuation depends on what you find on pathology.
What does it feel like to have fulminant myocarditis? How does it feel to see a loved one on ECMO? What impact do healthcare heroes have on their patients’ and their families’? Tune into this remarkable firsthand patient perspective as Chas and Julie Miller recount their experience with fulminant myocarditis. In Episode 31 we discussed the science & medicine of myocarditis. Now in Episode 32 we realize the emotions and human experience on the other side through the lens of a patient and his loving wife. Special messages from CCU nursing, Megan VanName, Alyssa Noonan, and Kelly Norsworthy, as well as Dr. Dan Choi, cardiac surgeon at Johns Hopkins Hospital.
The Cleveland Clinic Director of Cardiac MRI, Dr. Deborah Kwon, discusses the principles and clinical applications of cardiac MRI, taking us from the protons to the bedside with a series of illustrative cases. CardioNerds hosts Amit Goyal, Daniel Ambinder, and Carine Hamo are joined by Dr. Nicole Pristera (Cleveland Clinic cardiology fellow). Flutter moment by student doctor Arooma Shahid.
- How would you give a basic intro to CMR principles to a first year cardiology fellow?
- What should we know about the common sequences for cardiac MRI?
- We all learn about the risks of NSF. How much of these risks are a reality and when should we truly avoid gadolinium exposure?
- What are some challenges to MRI?
- What types of information about the heart can we obtain with a CMR?
CardioNerds (Amit Goyal & Daniel Ambinder) discuss a case report of COVID myocarditis and cardiogenic shock with Dr. Travis Howard and Dr. Zach Il’Giovine, cardiology fellows at the Cleveland Clinic. Dr. Nir Uriel, Professor of Medicine at Columbia University and Director of Advanced Heart Failure and Transplant at NewYork-Presbyterian Hospital Network in New York joins to discuss COVID-19 myocarditis and management of cardiogenic shock.
CardioNerds (Daniel Ambinder & Karan Desai) join Thomas Jefferson University FITs, Drs. Sean Dikdan, Rachel Debenham and Harsh Doshi. They discuss a profound story about a young man who presented with ventricular arrhythmias and cardiogenic shock that was ultimately found to be due to giant cell myocarditis. From the evaluation of cardiogenic shock to the role of endomyocardial biopsy to facing inequities in organ allocation, there are learning pearls for every listener! Dr. Enrico Ammirati, an advanced heart failure and transplant cardiologist in Milan, Italy, provides the E-CPR segment. For more insights from Dr. Ammirati, check out episodes 29 and 30 which feature an in-depth discussion on myocarditis with Dr. Ammirati, along with Drs. JoAnn Lindenfeld and Javid Moslehi. Audio editing by CardioNerds Academy intern, Gurleen Kaur.
- Pollack A, Kontorovich AR, Fuster V, Dec GW. Viral myocarditis-diagnosis, treatment options, and current controversies. Nat Rev Cardiol. 2015;12(11):670-680.
- Sinagra G, Anzini M, Pereira NL, et al. Myocarditis in Clinical Practice. Mayo Clin Proc. 2016;91(9):1256-1266. doi:10.1016/j.mayocp.2016.05.013
- Kociol RD, Cooper LT, Fang JC, et al. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement from the American Heart Association. Circulation. 2020:E69-E92.
- Leone O, Pieroni M, Rapezzi C, Olivotto I. The spectrum of myocarditis: from pathology to the clinics. Virchows Arch. 2019;475(3):279-301.
- Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation. 2019;139(18):E891-E908.
- Ammirati E, Frigerio M, Adler ED, et al. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy. Circ Hear Fail. 2020;13(11). doi:10.1161/CIRCHEARTFAILURE.120.007405
Myocarditis Youtube Lecture Series
Dr. Richa Gupta from Vanderbilt University Medical Center discusses what is known about myocardial injury in COVID-19 patients. Myocarditis diagnosis and treatment is reviewed and a paradigm for the clinical course of late presenting COVID-19 ARDS with systemic hyperimmune injury is described.
Dr. Richa Gupta from Vanderbilt University Medical Center discusses what is known about myocardial injury in COVID-19 patients. Treatment for COVID-19 related myocarditis is discussed including supportive management as well as a pharmacologic strategies under investigation that include antiviral agents, immune-modulators, statins, and convalescent plasma.
Meet our experts and guest hosts!
Richa Gupta, MD, MPH
Dr. Richa Gupta completed medical school at the Johns Hopkins School of Medicine and stayed on for internal medicine training in the Osler Residency Program at the Johns Hopkins Hospital. She is currently a third-year cardiology fellow at Vanderbilt University Medical Center where she will also be pursuing fellowship in advanced heart failure and transplant cardiology next year. Her current interests include post-transplant outcomes, the genetics of tachycardia-induced cardiomyopathy, the sequelae of mechanical circulatory support and applications of cardiac MRI. She also loves teaching the housestaff and medical students and getting them excited about all things heart failure. Outside of the hospital she loves horror movies, food, travel and good exercise.
JoAnn Lindenfeld, MD
Dr. JoAnn Lindenfeld, is a Professor of Medicine and the Director of Heart Failure and Heart Transplantation Section at Vanderbilt Heart and Vascular Institute. She is the past president of the Heart Failure Society of America and serves on editorial boards of numerous journals including JACC, JACC Heart Failure and JHLT. She is also a member of the AHA/ACC/HFSA heart failure guideline writing committee and was previously chair of the HFSA practice guidelines for the 2006 and 2010 guidelines. In addition to this she’s been an investigator in multiple large-scale clinical trials including the COAPT trial and has served on numerous steering committees, end point committees and data and safety monitoring committees. She is the author of a more than 300 original papers, reviews, and book chapters in the field of heart failure and heart transplantation.
Javid Moslehi, MD
Dr. Javid Moslehi is an associate professor of medicine at Vanderbilt University Medical Center where he is the director of the cardio-oncology program. He is a clinical cardiologist and basic/translational biologist interested in cardiovascular complications associated with novel molecular targeted cancer therapies and the implications of these on our knowledge of basic cardiovascular biology. At Vanderbilt he runs an independent basic and translational research laboratory and program with a focus on signal transduction in the myocardium and vasculature as well as establishing pre-clinical models of cardiotoxicity involving novel targeted oncologic therapies.
Enrico Ammirati MD, PhD, FESC
Dr. Enrico Ammirati is an assistant professor of cardiology and advanced heart failure and transplant cardiologist in Milan, Italy at the Niguarda Hospital with a special research interest and expertise in acute myocarditis and acute heart failure. He is a fellow of the European Society of Cardiology and has won numerous awards, he has also published incredibly important work on the distinction between fulminant and nonfulminant myocarditis and the prognostic implication of histologic subtypes. His research interests also include the role of adaptive immunity in heart transplantation and atherosclerosis and he is the author of well over 100+ peer reviewed publications.
Deborah Kwon, MD
Dr. Debbie Kwon attended medical school at the University of Michigan and internal medicine residency at the University of Pennsylvania. She completed her general cardiology and cardiovascular imaging fellowships at the Cleveland Clinic. She is the Director of Cardiac MRI At the Cleveland Clinic and serves as the Core Lab MRI director for the Pulmonary Vascular Disease Phenomics (PVDOMICS) multicenter National institution of Health (NIH) Study.
Nicole Pristera, MD
Dr. Nicole Pristera is a cardiology fellow at the Cleveland Clinic. She earned her medical degree at Case Western Reserve University and completed her internal medicine residency training at Duke University. Her clinical interests include interventional cardiology and cardiac critical care. Outside of the hospital, she enjoys traveling, hiking, and learning foreign languages.
Meet our Flutter Stars!
Beth Faiman, PhD, CNP
Matthew Faiman, MD
Dr. Matthew Faiman is a physician in the department of Internal Medicine. His primary location is Lyndhurst Campus.
Arooma Tahir, MBBS