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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 4, July/August 2019
AFRICA
239
Review Article
The role of echocardiography in acute viral myocarditis
Mamotabo R Matshela
Abstract
The diagnosis of acute viral myocarditis can be very chal-
lenging during the initial evaluation, warranting multiple
diagnostic tests to be performed, including a full echocar-
diographic evaluation to exclude other aetiologies that might
present similarly. Acute myocarditis may masquerade as
acute myocardial infarction in older patients or as any form
of cardiomyopathy in young patients. As a result, all these
patients need a thorough evaluation and to be managed at a
high cardiac-care setting from the very outset. A wide range
of diagnostic tests may be warranted, including conven-
tional echocardiography, to exclude other underlying cardiac
diseases, to evaluate cardiac chamber size, wall thickness,
ventricular function and the presence of pericardial collec-
tions, and to assist in guiding further management. Although
left ventricular dysfunction tends to be described more often,
right ventricular dysfunction has been reported as the most
likely cause of unfavourable outcomes, compared with left
ventricular dysfunction. Therefore it is important to thor-
oughly evaluate and report all echocardiographic parameters
for both ventricles and to determine the prognosis.
Keywords:
acute viral myocarditis, echocardiography, speckle-
tracking echocardiography
Submitted 26/6/17, accepted 16/11/18
Published online 11/4/19
Cardiovasc J Afr
2019;
30
: 239–244
www.cvja.co.zaDOI: 10.5830/CVJA-2018-069
Diagnosis of acute viral myocarditis can be challenging as its
clinical presentationmaymasquerade as other cardiac conditions,
such as an acute myocardial infarction. As a result, all patients
with suspected acute viral myocarditis should undergo thorough
evaluation, including a full echocardiographic assessment to
exclude other causes that could present in a similar fasion.
1-29
Most importantly, these patients need closer monitoring and
should be managed in a high-care or cardiac-care setting.
1
Diagnosis of acute viral myocarditis is based on the presenting
symptoms, elevated cardiac markers suggestive of myocardial
necrosis, and electrocardiographic and echocardiographic
changes. Although a wide range of diagnostic tests may be
warranted when initially evaluating these patients, conventional
echocardiography remains a crucial imaging modality to
exclude other underlying cardiac diseases, to evaluate cardiac
chamber size, wall thickness, ventricular function and presence
of pericardial collections, to differentiate fulminant from acute
myocarditis, and to help guide the patient’s management.
There is earlier information on the role of echocardiography in
myocarditis, however data on newor advanced echocardiographic
imaging modalities are limited; as a result, future research is
warranted in this area. Hence, the main objective of this article
was to review the role of different echocardiographic modalities
that may be useful during suspicion of acute viral myocarditis,
as well as to report on new or advanced echocardiographic
modalities to be applied during echocardiographic assessment,
including contrast and speckle-tracking echocardiography.
Two-dimensional transthoracic echocardiography
Conventional echocardiography forms a crucial component for
diagnostic work up in patients suspected of acute myocarditis.
30
Two-dimensional transthoracic echocardiography (2D-TTE) plays
a crucial role in evaluating ventricular function and excluding
other causes of chest pain or heart failure, including valvular,
congenital and ischaemic heart diseases, and pericardial diseases.
Previous data have extensively reported on acute myocarditis
as an important masquerader of acute myocardial infarction,
therefore regional wall-motion abnormalities should be looked
for during TTE, particularly in elderly patients or those with
traditional risk factors for coronary artery diseases, as opposed
to young, healthy athletes.
2-29
Even though 2D-TTE features of
acute myocarditis are non-specific, it is still useful to exclude
potential differentials, assist in guiding further management,
including follow ups, and for prognostic purposes.
Echocardiographic criteria for myocarditis
Despite the fact that echocardiographic diagnosis of acute
myocarditis has been hampered by non-specific features at the
time of examination, the diagnostic criteria were previously
suggested and have been adopted.
31-34
These criteria focus mainly
on distinguishing fulminant from acute myocarditis and are
very important in assisting triaging patients for specialised care,
depending on the disease stage.
Several studies have previously evaluated the role of
echocardiography during initial and follow-up management of
patients suspected of or confirmed with acute myocarditis.
Therefore echocardiography plays a crucial role and should be
implemented at the initial evaluation and during the follow up.
1-30,35
University of KwaZulu-Natal, Durban, Mediclinic Heart
Hospital, Pretoria, South Africa; London School of
Economics and Political Science, London, UK
Mamotabo R Matshela, MB ChB, PhD, FESC, mamotabomatsh@
gmail.com