Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w

To rest or not to rest: elective surgery under general anesthesia as a potential trigger for re-activating myocarditis

E. Unger1, D. Csengeri1, C. Magnussen1, D. Dum2, K. Müllerleile3, S. Blankenberg1, R. Schnabel1

1Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 2Institut für Pathologie mit den Sektionen Molekularpathologie und Zytopathologie, Universitätsklinikum Hamburg-Eppendorf, Zentrum für Diagnostik, Hamburg; 3Kardiologische Praxis Orchideenstieg, Hamburg;

Case summary A 23-year-old woman presented with on-and-off stabbing chest pain for 7 days independent of exertion as well as mild dyspnea upon exertion (NYHA II) at the emergency department. The patient reported a history of acute myocarditis 4 months ago. She had undergone general anesthesia (GA, induction: propofol, maintainance: sevoflurane) for laparoscopic endometrioma resection 2 weeks prior whilst being otherwise adherent to recommend physical resting and prescription drugs (low-dose Ramipril and Progestogen). Clinical examination, ECG and echocardiography were unremarkable. Troponin I plasma levels were significantly elevated with 33,537pg/ml and NT-pro-BNP mildly increased at 443ng/ml. The patient was admitted for suspected recurrent myocarditis. Serial testing of troponin I plasma levels showed a continuous rise to a peak of 1.6 mio pg/ml, maximum creatine kinase 402U/l. During hospitalization, the patient was hemodynamically stable without relevant arrhythmias. Cardiac magnetic resonance imaging (cMRI) showed preserved biventricular function in the absence of myocardial edema with circumferential epi- to midmyocardial late gadolinium enhancement (LGE) of the anterior, lateral and posterior left ventricular (LV) wall and the interventricular septum with elevated T1 and T2 times suggestive of extensive myocarditis. Coronary angiography demonstrated the absence of coronary artery disease. LV myocardial biopsy was performed and histopathological workup yielded an increase of CD3+ T-cells suggesting lymphocytic myocarditis with mild interstitial fibrosis and no evidence of significant necrosis. Polymerase-chain reaction (PCR)-testing of the biopsies did not detect cardiotropic viruses. The patient received high-dose iv steroids (250mg of Prednisolone) for 3 days with tapering over 8 weeks and Bisoprolol and Ramipril to be continued for 12 months. Short term cMRI follow up after 6 days consistently showed LGE with elevated T1 times with normalization of T2 times. Cardiac biomarker levels significantly decreased under immunosuppressive therapy (troponin I 904 pg/ml at day 7 of Prednisolone) and were closely followed-up in an outpatient setting. Discussion This case suggests the reactivation of myocarditis following laparoscopic surgery under general anesthesia with propofol and sevoflurane 4 months after acute myocarditis. The recommended period for abstinence from competitive sports after myocarditis is commonly approximated at 3-6 months by expert consensus. For professional athletes, it is recommended to undergo comprehensive testing not earlier than 3-6 months and resume training in the absence of arrhythmias when LV function and biomarkers (e.g. troponin I, NT-pro-BNP, CRP amongst others) are within normal range. Resolution of myocarditis-related LGE as a condition for return to competitive sport is under discussion. To date, there are no recommendations for eligibility to undergo GA after recovery from acute myocarditis. While volatile or intravenous anesthetics in themselves are reported to have both immunosuppressive as well as immunoactivating properties, stress is inherent in a perioperative setting and may trigger a systemic inflammatory response that is likely be mediated by anesthetic method. In this case, a potential perioperative activation in cell-mediated immunity may have caused reactivation of inflammation of vulnerable, recovering myocardium with extensive levels of serum troponin I and distinct imaging findings.

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