Case Series: Full Recovery in Severe ParvoB19 Myocarditis with DCM Phenotype: The Impact of rASD Creation and Pulmonary Banding

Thushiha Logeswaran^1*Hakan Akintuerk¹Matthias Mueller¹Lucie Rueblinger¹Kerstin Gummel¹Karin Klingel²Blanka Steinbrenner¹Christian Jux¹Dietmar Schranz³

• ¹Department of Pediatric Cardiology, Faculty of Medicine, University of Giessen, Giessen, Germany
• ²Cardiopathology, Institute for PAthology and Neuropathology, University Tuebingen, Tuebingen, Germany
• ³University Hospital Frankfurt, Frankfurt, Hesse, Germany

Background: The incidence of parvovirus B19 (B19V)-associated myocarditis progressing to dilated cardiomyopathy (DCM) is on the rise. We hypothesize that a comprehensive treatment regimen enables cardiac regeneration in young patients with life-threatening B19V myocarditis.Methods: Four patients with clinical and imaging evidence of DCM were referred due to suspected myocarditis. An endomyocardial biopsy (EMB) confirmed the diagnosis. The diastolic dysfunction associated with heart failure and reduced left ventricular ejection fraction (HFrEF) was established invasively. Before surgical pulmonary artery banding (PAB), a transcatheter procedure was performed to create a restrictive atrial defect (rASD).Results: The drug-treated patients (ages 15 to 26 months) had a mean LV-EF of 22.5% (20-25%), a left ventricular end-diastolic diameter (LVEDD) of 49 (45-51) mm (Z-score >5), and elevated LVED pressures (>18 mmHg). EMB revealed B19V-associated acute/subacute or chronic active myocarditis with characteristics of DCM. Drug therapy, including immunoglobulins and creating a rASD, resulted in clinical improvement and enhanced right ventricular function. However, LV enlargement and dysfunction persisted. Four weeks after surgical PAB, all patients showed improvement and were discharged home. The pressure gradient across the PAB ranged from 40 to 45 mmHg, and LVEDD decreased to a mean z-score of +3.5. Within three to six months, LVEDD normalized, and LV-EF increased to a mean of 63% (range: 57-68%). Clinical and cardiac improvements were sustained over a median follow-up of 7.5 years.A holistic treatment approach allows functional regeneration in B19V myocarditis with obvious end-stage DCM. Restrictive ASD creation is required before surgical PAB when HFpEF is associated with a diastolic dysfunction component.