Prior myocarditis and ventricular arrhythmias: The importance of scar pattern

Published:December 17, 2020DOI:


      Multiple studies have addressed the importance of anteroseptal scar in patients with nonischemic cardiomyopathy. However, this pattern has never been fully evaluated in patients with prior myocarditis.


      The purpose of this study was to evaluate whether anteroseptal scar is associated with worse outcome in patients with prior myocarditis and how it affects the efficacy of catheter ablation (CA).


      This was a retrospective study of consecutive patients with prior myocarditis and arrhythmic presentation. Cardiac magnetic resonance and electroanatomic voltage mapping were used to identify the scar pattern. Patients were referred for either CA or escalated antiarrhythmic drug (AAD) therapy. The main outcome was ventricular arrhythmia (VA)–free survival according to the presence of anteroseptal scar.


      A total of 144 consecutive patients with prior myocarditis were included. Mean age was 42.1 ± 14.9 years, and 58% were men. Ejection fraction was normal in 73% of patients. Anteroseptal scar was present in 44% of cases. Sixty-one patients (42%) underwent CA. Overall, at 2-year follow-up, VA-free survival was 77% in the CA group. After CA, the mean number of AADs taken by each patient decreased from 1.8 to 0.9 per day (p<0.001). The presence of anteroseptal scar was found to be an independent predictor of VA relapse both in patients treated with CA (hazard ratio [HR] 3.6; 95% confidence interval [CI] 1.1–11.4; P = .03) and in the overall population (HR 2.0; 95% CI 1.2–3.5; P = .02) .


      In patients with prior myocarditis and VA, the presence of anteroseptal scar negatively predicts outcomes irrespective of treatment strategy.


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        • Peretto G.
        • Sala S.
        • Rizzo S.
        • et al.
        Ventricular arrhythmias in myocarditis: characterization and relationships with myocardial inflammation.
        J Am Coll Cardiol. 2020; 75: 1046-1057
        • Maron B.J.
        • Udelson J.E.
        • Bonow R.O.
        • et al.
        Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology.
        J Am Coll Cardiol. 2015; 66: 2362-2371
        • Al-Khatib S.M.
        • Stevenson W.G.
        • Ackerman M.J.
        • et al.
        2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Heart Rhythm. 2018; 15: e190-e252
        • Priori S.G.
        • Blomstrom-Lundqvist C.
        • Mazzanti A.
        • et al.
        2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).
        Eur Heart J. 2015; 36: 2793-2867
        • Caforio A.L.P.
        • 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 Cardiology Working Group on Myocardial and Pericardial Diseases.
        Eur Heart J. 2013; 34 (2648a–2648d): 2636-2648
        • Kettering K.
        • Kampmann C.
        • Mollnau H.
        • Kreitner K.-F.
        • Munzel T.
        • Weiss C.
        Catheter ablation of an incessant ventricular tachycardia originating from the left aortic sinus cusp in an adolescent with subacute myocarditis.
        Clin Res Cardiol. 2009; 98: 66-70
        • Zeppenfeld K.
        • Blom N.A.
        • Bootsma M.
        • Schalij M.J.
        Incessant ventricular tachycardia in fulminant lymphocytic myocarditis: evidence for origin in the Purkinje system and successful treatment with ablation.
        Heart Rhythm. 2007; 4: 88-91
        • Dello Russo A.
        • Casella M.
        • Pieroni M.
        • et al.
        Drug-refractory ventricular tachycardias after myocarditis: endocardial and epicardial radiofrequency catheter ablation.
        Circ Arrhythm Electrophysiol. 2012; 5: 492-498
        • Oloriz T.
        • Silberbauer J.
        • MacCabelli G.
        • et al.
        Catheter ablation of ventricular arrhythmia in nonischemic cardiomyopathy: anteroseptal versus inferolateral scar sub-types.
        Circ Arrhythm Electrophysiol. 2014; 7: 414-423
        • Aquaro G.D.
        • Ghebru Habtemicael Y.
        • Camastra G.
        • et al.
        Prognostic value of repeating cardiac magnetic resonance in patients with acute myocarditis.
        J Am Coll Cardiol. 2019; 74: 2439-2448
        • Aquaro G.D.
        • Perfetti M.
        • Camastra G.
        • et al.
        Cardiac MR with late gadolinium enhancement in acute myocarditis with preserved systolic function: ITAMY Study.
        J Am Coll Cardiol. 2017; 70: 1977-1987
        • Simon G.
        • Andreas S.
        • MKA L.
        • et al.
        Predictors of mortality in patients with biopsy-proven viral myocarditis: 10-year outcome data.
        J Am Heart Assoc. 2020; 9e015351
        • Friedrich M.G.
        • Marcotte F.
        Cardiac magnetic resonance assessment of myocarditis.
        Circ Cardiovasc Imaging. 2013; 6: 833-839
        • Friedrich M.G.
        • Sechtem U.
        • Schulz-Menger J.
        • et al.
        Cardiovascular magnetic resonance in myocarditis: a JACC White Paper.
        J Am Coll Cardiol. 2009; 53: 1475-1487
        • Schumm J.
        • Greulich S.
        • Wagner A.
        • et al.
        Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis.
        J Cardiovasc Magn Reson. 2014; 16: 14
        • Corrado D.
        • van Tintelen P.J.
        • McKenna W.J.
        • et al.
        Arrhythmogenic right ventricular cardiomyopathy: evaluation of the current diagnostic criteria and differential diagnosis.
        Eur Heart J. 2019; 41: 1414-1429
        • Towbin J.A.
        • McKenna W.J.
        • Abrams D.J.
        • et al.
        2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy.
        Heart Rhythm. 2019; 16: e301-e372
        • Towbin J.A.
        • Lorts A.
        • Jefferies J.L.
        Left ventricular non-compaction cardiomyopathy.
        Lancet. 2015; 386: 813-825
        • Satoh H.
        • Sano M.
        • Suwa K.
        • et al.
        Distribution of late gadolinium enhancement in various types of cardiomyopathies: significance in differential diagnosis, clinical features and prognosis.
        World J Cardiol. 2014; 6: 585-601
        • Sechtem U.
        • Mahrholdt H.
        • Vogelsberg H.
        Cardiac magnetic resonance in myocardial disease.
        Heart. 2007; 93: 1520-1527
        • Vaughan Williams E.M.
        Classification of antidysrhythmic drugs.
        Pharmacol Ther B. 1975; 1: 115-138
        • Casella M.
        • Dello Russo A.
        • Bergonti M.
        • et al.
        Diagnostic yield of electroanatomic voltage mapping in guiding endomyocardial biopsies.
        Circulation. 2020; 142: 1249-1260
        • Zeppenfeld K.
        Ventricular tachycardia ablation in nonischemic cardiomyopathy.
        JACC Clin Electrophysiol. 2018; 4: 1123-1140
        • Mazzone P.
        • Tsiachris D.
        • Della Bella P.
        Epicardial management of myocarditis-related ventricular tachycardia.
        Eur Heart J. 2013; 34: 244
        • Peretto G.
        • Sala S.
        • Rizzo S.
        • et al.
        Arrhythmias in myocarditis: state of the art.
        Heart Rhythm. 2019; 16: 793-801
        • Berte B.
        • Sacher F.
        • Cochet H.
        • et al.
        Postmyocarditis ventricular tachycardia in patients with epicardial-only scar: a specific entity requiring a specific approach.
        J Cardiovasc Electrophysiol. 2015; 26: 42-50
        • Maccabelli G.
        • Tsiachris D.
        • Silberbauer J.
        • et al.
        Imaging and epicardial substrate ablation of ventricular tachycardia in patients late after myocarditis.
        Europace. 2014; 16: 1363-1372
        • Dinov B.
        • Fiedler L.
        • Schönbauer R.
        • et al.
        Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the prospective Heart Centre of Leipzig VT Study.
        Circulation. 2014; 129: 728-736
        • Muser D.
        • Santangeli P.
        • Castro S.A.
        • et al.
        Long-term outcome after catheter ablation of ventricular tachycardia in patients with nonischemic dilated cardiomyopathy.
        Circ Arrhythm Electrophysiol. 2016; 9: 1-11
        • Vaseghi M.
        • Hu T.Y.
        • Tung R.
        • et al.
        Outcomes of catheter ablation of ventricular tachycardia based on etiology in nonischemic heart disease: an international ventricular tachycardia ablation center collaborative study.
        JACC Clin Electrophysiol. 2018; 4: 1141-1150
        • Cronin E.M.
        • Bogun F.M.
        • Maury P.
        • et al.
        2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.
        J Arrhythm. 2019; 35: 323-484
        • Haqqani H.M.
        • Tschabrunn C.M.
        • Tzou W.S.
        • et al.
        Isolated septal substrate for ventricular tachycardia in nonischemic dilated cardiomyopathy: incidence, characterization, and implications.
        Heart Rhythm. 2011; 8: 1169-1176
        • Piers S.R.D.
        • Tao Q.
        • van Huls van Taxis C.F.B.
        • Schalij M.J.
        • van der Geest R.J.
        • Zeppenfeld K.
        Contrast-enhanced MRI-derived scar patterns and associated ventricular tachycardias in nonischemic cardiomyopathy: implications for the ablation strategy.
        Circ Arrhythm Electrophysiol. 2013; 6: 875-883
        • Della Bella P.
        • Peretto G.
        • Paglino G.
        • et al.
        Bipolar radiofrequency ablation for ventricular tachycardias originating from the interventricular septum: safety and efficacy in a pilot cohort study.
        Heart Rhythm. 2020; 17: 2111-2118