Evaluation of retrospective diagnosis of diagnosed myoocarditis between 0-18 years older involvement in children's health and diseases during 2009-2017 years

Objective: Myocarditis is an inflammatory disease of myocardium. In children, viral agents are often responsible for etiology. Incidence of myocarditis is unknown due to clinical presentation of the disease might be silent. Patients may be asymptomatic due to subclinical course or nonspecific systemic symptoms and some cases may have congestive heart failure and cardiogenic shock due to fulminant myocarditis. Sometimes clinical findings may interfere as systemic infections, metabolic disease, sepsis or pneumonia. Clinical suspicious is important for diagnosis of mycocarditis. Although the myocardial biopsy gold standard for diagnosis, it's seldom use nowadays due to their's complications and low sensitivity. Myocarditis is the most common cause of dilated cardiomyopathy and congestive heart failure in childhood. Aim of this study is to investigate the clinical findings, sociodemographic characteristics and follow - up of the myocarditis cases who we followed in our clinic between January 2009 - December 2017 and to evaluate the prognostic aspects of the disease and to determine the factors affecting the mortality. Patients and Methods: Echocardiography reports of patients who diagnosed myocarditis between January 2009 to December 2017 were included in this study. The medical datas of patient were reviewed and sex, date of admission, age at the time of admission, presence of previous infection, physical examination findings, serum cardiac markers, hemogram, C reactive protein and viral serology results, electrocardiographic findings, telecardiographic findings and the complications were analysed. Statistical analyzes performed with IBM SPSS 22.0. Pearson chi-square and continuity corrected chi-square tests were used. Numerical data were summarized with median, minimum and maximum values. Univariate Kaplan - Meier and Cox regression analyzes were used in comparisons. The significance level was accepted as 0.05 in all tests. Results: From January 2007 to December 2017, 67 patients with myocarditis who were followed up in the Pediatric Cardiology Clinic were retrospectively analyzed. Patient complaints were as follow; chest pain (7.5%), palpitation (5.9%), fainting (2.9%), rapid fatigue (1.5%), shortness of breath (28.3%), cough (7.5%), abdominal pain (2.9%), vomiting - diarrhea (2.9%), scorpion insertion (11.9%), fever (8.9%), malaise (4.5%), restlessness (1.5%), rash and swelling in the body (3%). 1 patient (1.5%) had cardiac arrest history, 2 patients (2.9%) wasconfusing, and 1 patient (1.5%) viii was intubated due to respiratory insufficiency. Physical examination findings revealed asgallop rythm (7.4%), tachycardia (17.8%), systolic murmur (22.3%), edema (4,5%), crepitant rales in pulmonary auscultation (8.9%), tachypnea (25.3%) and hepatomegaly (10.3%). C reactive protein was elevated in 14 patients (20.8%) and normal in 53 patients (79.2%). In 43 patients (64.2%) myoglobin was found as normal and high in 24 patients (35.8%). CK-MB value was found normal in 32 patients (47.8%) and high in 35 patients (52.2%). Troponin was found as normal in 40 patients (59.8%) and high in 27 patients (40.2%). The etiological factor was scorpion sting in 8 patients (11.9%). Viral serology were investigated in 46 patients (68.6%). 4.5% Parvovirüs, 2.9% EBV, 1.5% Rotavirüs, 1.5% Rhinovirüs, 1.5% HSV, 1.5% Mycoplasma were detected. Electrocardiography showed 4.47% supraventricular tachycardia, 20.89% sinus tachycardia and 31.4% voltage suppression. Telecardiograpy showed that pulmonary congestion with increase of cardiothoracic ratio in 19.4% of patients and the increase of cardiothoracic ratio in 19.4% of patients. On echocardiographic examination mean ejection fraction was 42.35% (min: 13%, max: 78%, standard deviation: ± 14,173) and the mean shortening fraction was 21.36% (min: 9%, max: 45% and standard deviation: ± 8,170). In medical treatment, 79.1% patients were received diuretic, 73.1% patients were received ACE inhibitors, 56.7% patients were received dopamine and dobutamine, 62.6% received digoxin and 13.4% patients were received milrinon. In additon to medical treatment 28.3% patients received IVIG treatment due to viral etiology received. Of the 67 patients, 31 (46.2%) were fully recovered. There was developed dilate cardiomyopathy in 21 patients (31.3%). Six patients were died in acute phase. 7 of 21 patients with dilate cardiomyopathy were died at follow-up period. Seven patients were referred to an cardiovasculer surgery center for VAD, ECMO or cardiac transplantation. The effect of telecardiographic findings on mortality was examined by univariate Kaplan - Meier analysis. Patients who have pulmonary congestion with increase of cardiothoracic ratio were compared with patients without pathologic findings in the telecardiography, it was determined that the survival time of patients without pathological findings was longer (p=0.033). Patients who have increase of cardiothoracic ratio and patients without pathologic findings on telecardography were compared and it was determined that the survival time of patients without pathological findings was longer (p=0.040). The effect of telecardiographic findings on mortality was examined by Cox regression analysis. Patients with increased cardiothoracic ratio had a 5.134 times more risk of death than patients without pathological telecardiography findings (Hazard ratio: 5.134 confidence interval: 1.165-22.625). Patients with increased cardiothoracic ratio and pulmonary congestion were found to have 3.805 times more risk of death than patients without pathological telecardiography findings (Hazard ratio: 3.805 confidence interval: 1.014-14.284). The mortality effect of the shortening fraction on echocardiography was investigated by Cox regression analysis. The 1 unit decrease of the shortening fraction increased mortality risk by 1.109 times (Hazard ratio: 1.109, confidence interval: 1.007-1.222). The mortality effect of myoglobin was assessed by univariate Kaplan-Meier analysis. Patients whose myoglobin levels were determined at normal limits had a longer survival time (p=0,004). Conclusion: Myocarditis is an inflammatorys disease of the myocardium. The etiology can be infectious and non-infectious. Diagnosis of myocarditis may be difficult to subtle clinical findings. The clinical picture may be varies from a mild subclinical period to congestive heart failure. Despite all therapeutic measures, mortality is very high. The prognosis varies from recovery to complicated chronic disease and death. Improvement of long-term and short-term prognosis will be achieved by improving treatment-oriented techniques and treatment approaches. In our study, increased cardiothoracic index and pulmonary congestion findings in telecardography, increased serum myoglobin level and decreased echocardiographic shortening fraction were found to increase mortality. The using the cardiac support devices in patients with myocarditis may decrease mortality. Key Words; Myocarditis, prognosis, mortality