Restrictive ASD and Reversible Pulmonary Artery Banding—A Comprehensive Approach in Infants with ParvoB19 Myocarditis

Background: The past decade has seen frequent associations of parvovirus B19 (B19V) with the pathogenesis of myocarditis (MC) and its progression toward dilated cardiomyopathy (DCM). This year (2024) showed a 4.5-fold increase in B19V compared with the mean of 2016 to 2023. A persistent dysfunction necessitates ongoing medical therapy and, in some cases, heart transplantation. While ParvoB19 myocarditis is potentially reversible, complete recovery is not always achievable, resulting in increased morbidity and mortality.

Methods: This case series demonstrates the beneficial impact of a comprehensive therapeutic approach, including creating a restrictive atrial septal defect (rASD) and performing a reversible pulmonary artery banding (rPAB). From September 2013 to September 2023, four pediatric patients with PCR-confirmed ParvoB19 myocarditis were included in this approach. The inclusion criteria for patient enrollment were age <3 years and severe dysfunction of the left ventricle (EF <25%) without improvement under heart failure therapy, including inotropic support.

Results: The median age of the patients was 18.5 months (range: 15–26 months), with a left ventricular ejection fraction (LVEF) of 22.5% (range: 20–25%) at admission. The left ventricular end-diastolic diameter (LVEDd) was 49 mm (range: 46–51 mm; z-score >4). Two patients required ventilation, and one survived a resuscitation episode. Endomyocardial biopsy (EMB) revealed ParvoB19, and histopathological analysis showed various spectrums of myocarditis. Cath laboratory intervention showed increased left ventricular end-diastolic pressure (mean: 20 mm Hg) in three patients, resulting in the creation of an rASD and thereby improving the right ventricular function and filling due to reduced postcapillary pulmonary hypertension. Persistent left ventricular dysfunction and dilatation led to the decision to perform an rPAB. All patients were discharged 4 weeks after PAB (pressure gradient 40–45 mm Hg). Improvement in LVEDD was already evident (mean 42 mm), following the concept that function follows form. The mean survival with total functional recovery in these four children was 7.5 years, with an LVEF of 60% and normalization of the LVEDd at the last follow-up.

Conclusion: Creating an rASD and performing an rPAB can improve the outcomes in patients with ParvoB19 myocarditis in various stages of inflammation. The immediate effect of interventricular septal shift improves the form of the left ventricle, positively affecting reverse-remodeling and enhancing functional recovery.

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Artikel online veröffentlicht:
11. Februar 2025