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Pediatric Fulminant Myocarditis in Japan: A Retrospective Nationwide Database Study of Hospital Volume, Management

Shingo Ohki¹, Koji Hosokawa¹, Shinichi Tomioka²

¹Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

|March 17, 2021

Insights

Pediatric fulminant myocarditis has high mortality, but treatment at high-volume centers significantly reduces in-hospital deaths. Higher case volumes in pediatric fulminant myocarditis correlate with better outcomes for critically ill children.

Area of Science:

Pediatric Cardiology
Critical Care Medicine
Epidemiology

Background:

Pediatric fulminant myocarditis is a severe form of acute myocarditis in children, characterized by critical illness.
Understanding factors influencing mortality in pediatric fulminant myocarditis is crucial for improving patient outcomes.
Previous studies have not fully elucidated the impact of hospital case volume on outcomes for this specific pediatric population.

Purpose of the Study:

To compare mortality and hospital stay between pediatric fulminant and non-fulminant myocarditis.
To describe management practices for pediatric fulminant myocarditis.
To evaluate the impact of clinical factors, including hospital case volume, on mortality in pediatric fulminant myocarditis.

Main Methods:

Retrospective observational study utilizing the Diagnosis Procedure Combination database (April 2012-March 2018) across over 1,000 Japanese acute care hospitals.
Inclusion of pediatric patients (<18 years) with acute myocarditis, specifically identifying fulminant cases based on critical interventions within 7 days.
Multivariable logistic regression and propensity score analyses were employed to assess factors associated with in-hospital mortality and the effect of hospital case volume.

Main Results:

The study included 866 pediatric patients; 44.1% had fulminant myocarditis with a 24.1% in-hospital mortality rate.
Fulminant myocarditis presented a 41.3-fold increased odds of mortality compared to non-fulminant cases (p < 0.001).
Factors associated with higher mortality in fulminant cases included younger age (≤5 years), mechanical ventilation, cardiopulmonary resuscitation, and renal replacement therapy.
Treatment at hospitals with the highest pediatric fulminant myocarditis case volume (≥6 cases in 6 years) was associated with significantly lower in-hospital mortality (OR, 0.30; 95% CI, 0.13-0.68) compared to the lowest tertile (1-2 cases).

Conclusions:

In-hospital mortality for pediatric fulminant myocarditis in Japan remains high.
Treatment at high-volume pediatric fulminant myocarditis centers is associated with a substantial reduction in mortality.
Further research is warranted to understand the mechanisms behind the improved outcomes observed at high-volume centers.

Read full analysis

Abstract

Objectives:

Pediatric fulminant myocarditis is a subset of pediatric acute myocarditis associated with critical illness. We aimed to compare mortality and other outcomes such as length of hospital stay between pediatric fulminant myocarditis and nonfulminant myocarditis. For the subgroup of patients with fulminant myocarditis, we also aimed to describe the current management practices and evaluate the impact of clinically relevant factors, including hospital case volume, on mortality.

Design:

Retrospective observational study using the Diagnosis Procedure Combination database from April 2012 to March 2018.

Setting:

Over 1,000 acute care hospitals in Japan.

Patients:

Patients with acute myocarditis less than 18 years old, including patients with fulminant myocarditis (i.e., those who received at least one of the following by day 7 of hospitalization: inotropes/vasopressors, mechanical circulatory support, or cardiopulmonary resuscitation).

Interventions:

None.

Measurements And Main Results:

Multivariable logistic regression analysis was conducted to investigate the association between clinically relevant factors and in-hospital mortality of patients with fulminant myocarditis. Furthermore, post hoc propensity score analyses (propensity score-adjusted, propensity score-matched, and inverse probability of treatment-weighted analyses) were performed to confirm the effect of hospital case volume on in-hospital mortality. In total, 866 pediatric patients with acute myocarditis were included, and 382 (44.1%) were categorized as fulminant myocarditis. In-hospital mortality for those with fulminant myocarditis was 24.1%. fulminant myocarditis was associated with 41.3-fold greater odds of mortality than nonfulminant myocarditis (95% CI, 14.7-115.9; p < 0.001). In the subgroup of patients with fulminant myocarditis, a higher in-hospital mortality was significantly associated with younger age (≤ 5 yr; odds ratio, 3.41; 95% CI, 1.75-6.64) and the need for either mechanical ventilation (odds ratio, 2.39; 95% CI, 1.03-5.57), cardiopulmonary resuscitation (odds ratio, 10.63; 95% CI, 5.52-20.49), or renal replacement therapy (odds ratio, 2.53; 95% CI, 1.09-5.87) by day 7. A lower in-hospital mortality rate was significantly associated with treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr; odds ratio, 0.30; 95% CI, 0.13-0.68) compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). Post hoc propensity score analyses consistently supported the primary results.

Conclusions:

In-hospital mortality of pediatric fulminant myocarditis in Japan remains high. Treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr) was associated with a 70% relative reduction in odds of in-hospital mortality compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). The reasons for such differences need further study.

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