High prevalence of viral genomes and multiple viral infections in the myocardium of adults with "idiopathic" left ventricular dysfunction

Purpose: For a long time, enteroviruses have been considered to be the most common cause of acute viral myocarditis (MC), with possible transition from MC to dilated cardiomyopathy (DCM). Recent investigations have shown, however, that other viruses are also frequently encountered in MC patients, suggesting that persistence of various virus species may play a pathogenic role in the transition from MC to DCM. The purpose of this study was to screen endomyocardial biopsies (EMBs) from patients with "idiopathic" DCM for the presence of viral genomes by using polymerase chain reaction (PCR) to assess the frequency of cardiac viral infections that may be involved in the pathogenesis of the disease. Methods: EMBs were obtained for PCR analysis from 100 consecutive patients (median left ventricular ejection fraction, 35.0%; range, 9% to 45%). PCR was performed to detect the genomic sequences of enterovirus (EV), adenovirus (ADV), human cytomegalovirus (HCMV), herpes simplex virus, Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), parvovirus B19 (PVB19), influenza A and B viruses and Coxiella burnettii. Myocardial inflammation was assessed by histological and immunohistological analyses. Results: Viral genomes could be amplified from EMBs of 85 (85%) of the 100 DCM patients: EV=25 (29%), ADV=5 (6%), PVB-19=10 (12%), HHV-6/7 =10 (12%), EBV=8 (9%), HCMV=6 (7%), including n= 10 cases (10%) with multiple infections. Active or borderline myocarditis according to the Dallas classification did not exist in any case. Conclusions: Viral genomes were frequently detected in EMBs of patients with systolic left ventricular dysfunction. Our data suggest that myocardial persistence of various viruses, often presenting as multiple infections, play a role in the pathogenesis of DCM far more frequently than suspected so far.