Review of Viral Myocarditis

1. Oleh:
dr. Zakky Hazami
Pembimbing:
dr. Amar Widhiani , SpA(K)
DEPARTMENT OF PEDIATRICS
HARAPAN KITA WOMEN AND CHILDREN HOSPITAL
2018
MIOKARDITIS VIRUS

2. Pendahuluan
Etiologi
Patofisiologi
Gambaran Klinis dan Diagnosis
Tatalaksana
Kesimpulan

3. PENDAHULUAN
Miokarditis virus merupakan inflamasi
akut atau kronik pada miokard yang
disebabkan oleh infeksi virus.
Miokarditis virus akut biasanya subklinis dan
dapat membaik dengan spontan, terapi terhadap
kronik miokarditis virus masih belum memuaskan
Kemungkinan MiokarditisVirus menjadi Autoimun
dan kardiomiopati
Canter CE, Simpson KE.Circulation. 2014
Arola A, Pikkarainen E, et all. J Am Heart Assoc 2017; 6
Freedman SB, Haladyn JK, Floh A, et al. Pediatrics 2007;

4. PENDAHULUAN
Insidensi kasus miokarditis 1-
2/100.000 anak pertahun
Penggunaan imunosupresi dan
imunomodulasi pada terapi
miokarditis akut masih
kontroversi
Butts RJ, Boyle GJ, Deshpande SR, et al. Pediatr Cardiol 2017; 38:1175
Miyake CY, Teele SA, Chen L, et al. Am J Cardiol 2014

5. ETIOLOGI
,
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173
Robinson J, Hartling L, Vandermeer B, Klassen TP.2015.

6. ETIOLOGI
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012;
28:1173
Robinson J, Hartling L, Vandermeer B, Klassen TP.2015.

7. PATOFISIOLOGI
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173.
Pieske B, Garcia-pavia P, Tscho C, Dominguez F, Ku U. . Reemergence of Endomyocardial
Biopsy. 2016;69(2):178–87.

8. PATOFISIOLOGI
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173.
Pieske B, Garcia-pavia P, Tscho C, Dominguez F, Ku U. . Reemergence of Endomyocardial
Biopsy. 2016;69(2):178–87.

9. PATOFISIOLOGI
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173.
Pieske B, Garcia-pavia P, Tscho C, Dominguez F, Ku U. . Reemergence of Endomyocardial Biopsy.
2016;69(2):178–87.

10. PATOFISIOLOGI
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173.
Pieske B, Garcia-pavia P, Tscho C, Dominguez F, Ku U. . Reemergence of Endomyocardial Biopsy.
2016;69(2):178–87.

11. GAMBARAN KLINIS
 Gejala prodormal infeksi virus: Demam, mialgia, dan malaise beberapa hari
sebelum onset terjadinya gangguan pada jantung ( riawayat infeksi saluran
respirasi atau saluran cerna sebelumnya)
 Gejala yang tidak spesifik : Gejala dan tanda yang tidak spesifik seperti distress
nafas atau gangguan saluran cerna seperti ( anoreksia, nyeri perut, dan muntah).
 Tanda dan gejala gagal jantung : Bayi dan anak biasanya memiliki gejala dan
tanda gagal jantung seperti sesak nafas, intoleransi aktivitas, sinkop, takipnea,
takikardi yang menetap, dan hepatomegali
 Arrhythmia: SVT,VT, AV block ,Vf dapat terjadi
 Miokarditis Fulminan : Suatu miokarditis virus dengan gambaran klinis yang
berat , hemodinamik yang tidak stabil
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173
Zhao L, Fu Z. Roles of Host Immunity in Viral Myocarditis and Dilated Cardiomyopathy. J Immunol Res [Internet]. 2018
Arola A, Pikkarainen E, Sipilä JO, et al. J Am Heart Assoc 2017; 6.

12. GAMBARAN KLINIS
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012; 28:1173
Zhao L, Fu Z. Roles of Host Immunity in Viral Myocarditis and Dilated Cardiomyopathy. J Immunol Res [Internet]. 2018
Arola A, Pikkarainen E, Sipilä JO, et al. J Am Heart Assoc 2017; 6.
Butts RJ, Boyle GJ, Deshpande SR, et al. Pediatr Cardiol 2017; 38:1175.

13. PEMERIKSAAN FISIK
Respirasi  Takipnea, retraksi, dan ronki karena peningkatan
tekanan atrium kiri dan kongesti vena pulmoner
Jantung:
S3 S4 gallop bisa didapatkan
Dilatasi RV , LV yang berat, murmur diastolik
Pada akut miokarditis fulminan didapatkan gambaran Low
Output syndrome
Pericardial friction rub
Canter CE, Simpson KE..circulation.2014
Freedman SB, Haladyn JK, Floh A, et al. Pediatrics 2007
Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. How to approach the great mimic? Expert Rev Cardiovasc Ther. 2016;14(1):105–15.
Butts RJ, Boyle GJ, Deshpande SR, et al. Pediatr Cardiol 2017; 38:1175

14. DIAGNOSIS
Evaluasi awal:
EKG : ST segment yang abnromal, misal T wave
inversion, ST elevasi, heart block,aksis yang abnormal,
low voltage
Ekokardiografi : Gangguan fungsi diatolik dan sistolik,
segmental atau global regional gerakan yang abnormal
(RWMA)
Lab:Troponin, NT-Pro BNP, CK, CKMB yang meningkat
Chest X-Ray:Penemuan yang tidak spesifik seperti
kardiomegali, kongesti vaskular pulmonal, efusi pleura
Canter CE, Simpson KE..circulation.2014
Freedman SB, Haladyn JK, Floh A, et al. Pediatrics 2007

15. DIAGNOSIS
Gold Satndart:
Biopsi EndoMyocardial (EMB)
 Alternatif dengan sensitifitas tinggi:
 CMR (Cardiac Magnetic Resonance)
 Light microscopy (Dallas criteria)
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-BiltagiM, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.

16. DIAGNOSIS
 Alternatif dengan SensitifitasTinggi:
 Biomolekular tekhnik – (PCR)in situ hybridization and polymerase chain
reaction amplification of viral DNA
 Imunositokimia – mendeteksi inflamasi pada biopsi EMB dengan
mengunakan monoclonal and polyclonal antibodies terhadap white blood
cell subsets including anti-CD3,T lymphocytes, anti-CD68, macrophages,
and anti-HLA-DR.
 Kultur virus –Viral culture of biopsy specimens may identify an etiology of
myocarditis
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-BiltagiM, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.

17. Butts RJ, Boyle GJ, Deshpande SR, et al.. PediatrCardiol 2017; 38:1175.

18. Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.

19. BIOPSI
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
. Gambar beberapa tipe miokarditis, A: Akut limfositik miokardiris dengan fokal inflamasi infiltrat sel B: sarkoidosis kardiak dengan
gambaran granuloma (panah hitam), C: Giant Cell Miokarditis dengan gambaran Giant Multinucleated cell( oanah kuning), D:
Miokarditis eosinofilik

20. Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.

21. Butts RJ, Boyle GJ, Deshpande SR, et al. Pediatr Cardiol 2017; 38:1175
CMR

22. Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-BiltagiM, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.

23. Pollack A, Kontorovich AR, Fuster V, Dec GW. Viral myocarditis-diagnosis, treatment options, and current controversies. Nat Rev Cardiol. 2015;12(11):670–80.

24. MANAGEMENT AND
TREATMENT
Fase Akut:
 Stabilisasi Hemodinamik Tatalaksana awal termasuk pemberian
oksigen , resusitasi cairan, support nutrisi, transfusi darah, inotropik, mekanikal
ventilasi, dan ECMO atauVAD
 Optimalisasi terapi : Diuretik,ACE-i, antiartmia, IVIG (2g/kgbb/24
jam), kortikosteroid
 Mechanical support : Pada gangguan sirkulasi berat terkadang
dibutuhkan penggunaan supor mekanik seperti ECMO atauVAD
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-BiltagiM, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.

25. Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-Biltagi M, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.
Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. How to approach the great mimic? Rev Cardiovasc Ther. 2016;14(1):105–15.

26. Aziz KU, Patel N, Sadullah T, Tasneem H, Thawerani H, Talpur S: a prospective randomised study. 2010;509–15.
Lazaros G, Oikonomou E, Tousoulis D Expert Rev Cardiovasc Ther [Internet]. 2017;0(0). Available from: http://dx.doi.org/10.1080/14779072.2017.1262764

27. Pada studi tahap 2 yang mengikutsertakan 22 pasien dengan
miokarditis virus atau kardiomiopati dengan persistensi virus ,
pemberian interferon-b (Beneferon) 18x106 IU/minggu selama 24v
minggu menunjukan eliminasi baik enterovirus dan adenovirus dan
perbaikan hemodinamik terutama perbaikan fraksi ejeksi LV
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-Biltagi M, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510. : a prospective randomised study. 2010;509–15.
Aziz KU, Patel N, Sadullah T, Tasneem H, Thawerani H, Talpur S.

28. TATALAKSANA
Fase Kronik:
 Gagal Jantung Kronik  Pada pasien dengan
miokarditis akut yang berkembang menjadi gagal
jantung kronis, optimalisasi terapi diuretik, digoxin,
penyekat beta, dan inhibisi aldosteron, rehabilitasi
medik dianjurkan
Butts RJ, Boyle GJ, Deshpande SR, et al.. Pediatr Cardiol 2017; 38:1175.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Pediatr Emerg Care 2012
Al-Biltagi M, Issa M, Hagar HA, et al. Acta Paediatr 2010; 99:1510.

29. KESIMPULAN

30.  Miokarditis harus dicurigai pada anak dengan onset akut gagal jantung
tanpa riwayat gangguan struktur jantung, khususnya pasca infeksi virus
atau dengan gejala prodormal infeksi virus
 Tatalaksana miokarditis virus dapat dipertimbangkan berdasarkan fase
atau tahapan perjalanan penyakit
 Secara keseluruhan prognosis miokarditis umumnya baik, dengan
kebanyakan kasus mengalami resolusi sempurna tanpa gangguan
jantung, namun kebanyakan mengalami intervensi dan mendapatkan
tatalaksana intensif selama fase akut

31. Daftar Pustaka
1. Canter CE, Simpson KE. Diagnosis and treatment of myocarditis in children in the
current era. Circulation 2014; 129:115.
2. Arola A, Pikkarainen E, Sipilä JO, et al. Occurrence and Features of Childhood
Myocarditis:A Nationwide Study in Finland. J Am Heart Assoc 2017; 6.
3. Freedman SB, Haladyn JK, Floh A, et al. Pediatric myocarditis: emergency
department clinical findings and diagnostic evaluation. Pediatrics 2007; 120:1278.
4. Butts RJ, Boyle GJ, Deshpande SR, et al. Characteristics of Clinically Diagnosed
Pediatric Myocarditis in a Contemporary Multi-Center Cohort. Pediatr Cardiol
2017; 38:1175.
5. Miyake CY,Teele SA, Chen L, et al. In-hospital arrhythmia development and
outcomes in pediatric patients with acute myocarditis. Am J Cardiol 2014;
113:535.
6. Butts RJ, Boyle GJ, Deshpande SR, et al. Characteristics of Clinically Diagnosed
Pediatric Myocarditis in a Contemporary Multi-Center Cohort. Pediatr Cardiol
2017; 38:1175.
7. Eisenberg MA, Green-Hopkins I, Alexander ME, ChiangVW. Cardiac troponinT as
a screening test for myocarditis in children. Pediatr Emerg Care 2012; 28:1173.

32. 8. Eisenberg MA, Green-Hopkins I, Alexander ME, ChiangVW. Cardiac troponinT as a
screening test for myocarditis in children. Pediatr EmergCare 2012; 28:1173.
9. Al-Biltagi M, Issa M, Hagar HA, et al. Circulating cardiac troponins levels and cardiac
dysfunction in children with acute and fulminant viral myocarditis. Acta Paediatr
2010; 99:1510.
10. Sachdeva S, Song X, Dham N, et al. Analysis of clinical parameters and cardiac
magnetic resonance imaging as predictors of outcome in pediatric myocarditis. Am
J Cardiol 2015; 115:499.
11. Foerster SR, Canter CE, Cinar A, et al.Ventricular remodeling and survival are more
favorable for myocarditis than for idiopathic dilated cardiomyopathy in childhood:
an outcomes study from the Pediatric Cardiomyopathy Registry. Circ Heart Fail
2010; 3:689.
12. Banka P, Robinson JD, Uppu SC, et al. Cardiovascular magnetic resonance
techniques and findings in children with myocarditis: a multicenter retrospective
study. J Cardiovasc Magn Reson 2015; 17:96.
13. de Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric Advanced Life Support:
2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S526.

33. 14. Miyake CY,Teele SA, Chen L, et al. In-hospital arrhythmia development and
outcomes in pediatric patients with acute myocarditis. Am J Cardiol 2014; 113:535.
15. Robinson J, Hartling L,Vandermeer B, KlassenTP. Intravenous immunoglobulin for
presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2015;
:CD004370.
16. Casadonte JR, Mazwi ML, Gambetta KE, et al. Risk Factors for Cardiac Arrest or
Mechanical Circulatory Support in Children with Fulminant Myocarditis. Pediatr
Cardiol 2017; 38:128.
17. Chen HS,Wang W,Wu SN, Liu JP. Corticosteroids for viral myocarditis. Cochrane
Database Syst Rev 2013; :CD004471.
18. Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology,
diagnosis, management, and therapy of myocarditis: a position statement of the
European Society of CardiologyWorking Group on Myocardial and Pericardial
Diseases. Eur Heart J 2013; 34:2636.
19. Morales DL, Almond CS, Jaquiss RD, et al. Bridging children of all sizes to cardiac
transplantation: the initial multicenter North American experience with the Berlin
Heart EXCOR ventricular assist device. J Heart LungTransplant 2011; 30:1.
20. Klugman D, Berger JT, Sable CA, et al. Pediatric patients hospitalized with
myocarditis: a multi-institutional analysis. Pediatr Cardiol 2010; 31:222.