Hostname: page-component-cd9895bd7-jkksz Total loading time: 0 Render date: 2024-12-26T17:41:58.363Z Has data issue: false hasContentIssue false
  • English
  • Français

QRS fragmentation in children with suspected myocarditis: a possible additional diagnostic sign

Published online by Cambridge University Press:  29 May 2020

Paolo Ferrero Open the ORCID record for Paolo Ferrero [Opens in a new window]  and
Isabelle Piazza
Paolo Ferrero*
Affiliation:
Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
Isabelle Piazza
Affiliation:
Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy University of Studies of Milan, Milan, Italy
*
Author for correspondence: Paolo Ferrero, Cardiovascular Department, Papa Giovanni XXIII Piazza OMS 1, 24127Bergamo, Italy. Tel: +39 3338088805; Fax: +39 0352674965; E-mail: pferrero@asst-pg23.it
Get access Rights & Permissions [Opens in a new window]

Abstract

Aims:

We aim to assess the diagnostic role of QRS fragmentation in children with suspected acute myocarditis.

Background:

Diagnosis of myocarditis in the paediatric population is challenging. Clinical suspicion, electrocardiogram, and laboratory tests are the main diagnostic features at presentation. However, electrocardiogram in patients with myocarditis is usually considered aspecific. We have previously described QRS fragmentation in adult patients with acute myocarditis.

Methods:

Patients aged less than 18 years, admitted between 2003 and 2019, and discharged with a diagnosis of acute myocarditis were included. Standard electrocardiogram, laboratory, and echocardiographic findings at admission and follow-up were reviewed. QRS fragmentation was defined by the presence of multiphasic R′ spikes. Cardiac magnetic resonance and biopsy were performed in selected patients.

Results:

Twenty-one patients were analysed, 16 males (76%), median age 9.5 (2.5–16) years. At presentation, 12 patients (57%) displayed QRS fragmentation. Median ejection fraction was 40% (27–60). Nine patients (43%) underwent cardiac magnetic resonance and displayed late gadolinium enhancement. One patient underwent biopsy that showed borderline findings. Electrocardiogram leads showing QRS fragmentation correlated with distribution of late gadolinium enhancement. Median follow-up was 600 (190–2343) days. All patients were alive at last follow-up. Six patients (33%) patients displayed persistence of QRS fragmentation. Median ejection fraction was 60% (60–65%). In three patients (14%), ejection fraction remained depressed, two of which showed persistence of QRS fragmentation.

Conclusion:

In this cohort of children with suspected myocarditis, QRS fragmentation was confirmed as a new additional diagnostic finding to look for at admission and during follow-up.

Keywords

Myocarditiselectrocardiogrampediatricdiagnosis
Type
Original Article
Information
Cardiology in the Young , Volume 30 , Issue 7 , July 2020 , pp. 962 - 966
Copyright
© The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Lipshultz, SE, Law, YM, Asante-Korang, A, et al.Cardiomyopathy in children: classification and diagnosis. A scientific statement from the American heart association. Circulation 2019; 140: e9–68.CrossRefGoogle ScholarPubMed
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: 689–697.CrossRefGoogle ScholarPubMed
Bouin, A, Gretteau, PA, Wehbe, M, et al.Enterovirus persistence in cardiac cells of patients with idiopathic dilated cardiomyopathy is linked to 5′ terminal genomic RNA-deleted viral populations with viral-encoded proteinase activities. Circulation 2019; 139: 2326–2338.CrossRefGoogle ScholarPubMed
Buttà, C, Zappia, L, Laterra, G, Roberto, M.Diagnostic and prognostic role of electrocardiogram in acute myocarditis: a comprehensive review. Ann Noninvasive Electrocardiol 2020; 25(3). doi: 10.1111/anec.12726.CrossRefGoogle ScholarPubMed
Lv, J, Han, B, Wang, C, et al.The clinical features of children with acute fulminant myocarditis and the diagnostic and follow-up value of cardiovascular magnetic resonance. Front Pediatr 2019; 7: 388.CrossRefGoogle ScholarPubMed
Ferrero, P, Piazza, I, Grosu, A, Brambilla, P, Sironi, S, Senni, M.QRS fragmentation as possible new marker of fibrosis in patients with myocarditis. Preliminary validation with cardiac magnetic resonance. Eur J Heart Fail 2019; 21: 1160–1161.CrossRefGoogle ScholarPubMed
Redfors, B, Kosmidou, I, Crowley, A, et al.Prognostic significance of QRS fragmentation and correlation with infarct size in patients with anterior ST-segment elevationmyocardial infarction treated with percutaneous coronary intervention: insights from the INFUSE-AMI trial. Int J Cardiol 2018; 253: 20–24.CrossRefGoogle Scholar
Jain, R, Singh, R, Yamini, S, Das, MK.Fragmented ECG as a risk marker in cardiovascular diseases. Curr Cardiol Rev 2014; 10: 277–286.CrossRefGoogle ScholarPubMed
Das, MK, Maskoun, W, Shen, Cet al.Fragmented QRS on twelve-lead electrocardiogram predicts arrhythmic events in patients with ischemic and non-ischemic cardiomyopathy. Heart Rhythm 2010; 7: 74–80.CrossRefGoogle Scholar
Abe, T, Tsuda, E, Miyazaki, A, Ishibashi-Ueda, H, Yamada, O.Clinicalcharacteristics and long-term outcome of acute myocarditis in children. Heart Vessels 2013; 28: 632–638.CrossRefGoogle Scholar
Durani, Y, Egan, M, Baffa, J, Selbst, SM, Nager, AL.Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009; 27: 942–947.CrossRefGoogle ScholarPubMed
Martinez-Villar, M, Gran, F, Sabaté-Rotés, A, et al.Acute myocarditis with infarct-like presentation in a pediatric population: role of cardiovascular magnetic resonance. Pediatr Cardiol 2018; 39: 51–56.CrossRefGoogle Scholar
Haukilahti, MA, Eranti, A, Kenttä, T, Huikuri, HV.QRS fragmentation patterns representing myocardial scar need to be separated from benign normal variants: hypotheses and proposal for morphology based classification. Front Physiol 2016; 7: 653.CrossRefGoogle ScholarPubMed
Pietrasik, G, Zaręba, W.QRS fragmentation: diagnostic and prognostic significance. Cardiol J 2012; 19: 114–121.CrossRefGoogle ScholarPubMed
Małek, ŁA, Kamińska, H, Barczuk-Falęcka, M, et al.Children with acute myocarditis often have persistent subclinical changes as revealed by cardiac magnetic resonance. J Magn Reson Imag 2020. doi: 10.1002/jmri.27036 [Epub ahead of print].CrossRefGoogle ScholarPubMed
English, RF, Janosky, JE, Ettedgui, JA, Webber, SA.Outcome of children with myocarditis Cardiol Young 2004; 14: 488–493.CrossRefGoogle ScholarPubMed
Klugman, D, Berger, JT, Sable, CA, He, J, Khandelwal, SG, Slonim, AD.Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol 2010; 31: 222–228.CrossRefGoogle ScholarPubMed
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: 535–540.CrossRefGoogle ScholarPubMed
Anderson, BR, Silver, ES, Richmond, ME, Liberman, L.Usefulness of arrhythmias as predictors of death and resource utilization in children with myocarditis. Am J Cardiol 2014; 114: 1400–1405.CrossRefGoogle ScholarPubMed