key: cord-0876255-fp1v2fxr
authors: Peretto, Giovanni; De Luca, Giacomo; Campochiaro, Corrado; Palmisano, Anna; Busnardo, Elena; Sartorelli, Silvia; Barzaghi, Federica; Cicalese, Maria Pia; Esposito, Antonio; Sala, Simone
title: Telemedicine in myocarditis: Evolution of a mutidisciplinary “disease Unit” at the time of COVID-19 pandemic()()
date: 2020-08-12
journal: Am Heart J
DOI: 10.1016/j.ahj.2020.07.015
sha: f066b5b9787fc0298e76718e1e6d12de64ee60a9
doc_id: 876255
cord_uid: fp1v2fxr

Myocarditis Disease Unit (MDU) is a functional multidisciplinary network designed to offer multidisciplinary assistance to patients with myocarditis. More than 300 patients coming from the whole Country are currently followed at a specialized multidisciplinary outpatient clinics. Following the pandemic outbreak of the SARS-CoV-2 infection in Italy, we present how the MDU rapidly evolved to a “tele-MDU”, via a dedicated multitasking digital health platform.

multidisciplinary "Disease Unit" for myocarditis rapidly evolved, to comply with the COVID-19related national health emergency. No extramural funding was used to support this work. The authors are solely responsible for the design, analyses and editing of the paper.

In last years, efforts have been made at our Institution, to offer multidisciplinary assistance to patients with myocarditis. In fact, myocarditis is an extremely complex disease from multiple wiewpoints: clinical, since almost all cardiological presentations have been described at the disease onset, ranging from infarct-like chest pain, to heart failure, to a broad spectrum of arrhythmias (2); diagnostic, since baseline workup includes both endomyocardial biopsy (EMB), as the recognized gold standard for histotyping and etiology definition, and noninvasive panoramic imaging techniques like cardiac magnetic resonance of positron emission tomography (2, 3) ; prognostic, since natural history ranges from mild self-limiting disease, to acute-phase fatal complications, or chronic evolution towards dilated cardiomyopathy (2, 4) ; therapeutical, since on top of cardiological treatment, etiology-specific therapy including immunosuppression may be required (2, 5) .

In 2013 we created a dedicated Myocarditis Disease Unit (MDU) at our Institution, to provide multidisciplinary care to all our patients with myocarditis. In particular, as a third-level referral center for arrhythmia management, we mainly focused on myocarditis patients with arrhythmic manifestations (6, 7 

Following the pandemic outbreak of the SARS-CoV-2 infection, the Italian Government directives forced citizens to a drastic reduction of their mobility. As an additional limiting factor, our Institution was selected as a COVID-19 referral center within a defined hub-and-spoke network involving all surrounding hospitals (8) . Subsequently, the entire in-hospital activity was rapidly reorganized, to face the ongoing healthcare emergency. In particular, in-hospital length of stay for the non-COVID patients was reduced to a minimum; all non-life saving procedures, including nonemergent EMB, were indefinetly postponed; and all outpatients clinics, including the myocarditis polyambulatory, were forced to a temporay closure (8) .

Thus, to meet the needs of both our historical patient cohort, and the newly-diagnosed myocarditis cases, we rapidly reorganized the entire MDU to transfer our multidiciplinary activity on a virtual platform.

HealthMeeting®, developed by Wezen Technologies s.r.l., is a HTML5 web platform designed to organize multidisciplinary activities. Participants can attend meetings by using any kind of desktop, tablet or smartphone device. Medical reports and images are integrated in the platform through a middleware managing all HL7 and DICOM data flows. A bidirectional link connects the platform with the local hospital software, containing clinical data of both inpatients and outpatients visited at our Institution. Communication is allowed among medical specialists via video and audio teleconferencing. Patients can be invited to join meetings, but do not have direct access to the platform. Privacy and sensitive data are protected by both cybersecurity, and special support from the legal office at our Institution. In particular, all the involved physicians were required to fill dedicated registration forms. Ad-hoc informed consent was also obtained from all patients before J o u r n a l P r e -p r o o f Journal Pre-proof their enrollment. For both patients and phisicians, the software supporting the platform was offered at no costs. The main features of the platform are summarized in Figure 1 and online supplements.

Referring to our MDU, the platform allowed for multiple tasks: 1) creating a "multidisciplinary report" with specific indications by any specialist involved, regarding diagnostic tests, follow-up exams, and treatment modification; 2) sharing reports with the patient; 3) reporting regular updates about patients follow-up, including required exams and pictures upload, with respect to the timeschedule planned at a real outpatient chekup visit; 4) discussing updates among members of the "tele-MDU"; 5) communicating multidisciplinary recommendations to the patient, anytime during follow-up, until the discharge from MDU.

As shown in Figure 2 , tele-MDU was applied to both inpatient and outpatient arenas. In particular, the new cases of clinically suspected myocarditis underwent forced early discharge from hospital, while still waiting for the results of EMB: by digital health technology, results of EMB were communicated to patients and, following an oral tele-interview to exclude any contraindication, optimal etiology-based treatment was promptly started (2, 5) . Deployment of such a system on inpatients allowed for subsequent transition of care to the outpatient setting. Provided patient written informed consent, there were no resrictions to tele-MDU application, and the model was virtually extended to the whole outpatient cohort. Although all cases were discussed in a team, to optimize resources and save time, most of the televisists were performed by designated referral physicians ( Figure 1 ). Hybrid models were applied, including video/phone calls, secure email correspondence, and in-person visits for urgent cases. Priority was given to patient requiring prompt decision making, as those at beginning/termination of immunosuppressive therapy, or those with any sign or symptom suggesting clinical instability. Otherwise, the chronological order of visits was J o u r n a l P r e -p r o o f Journal Pre-proof followed, as prior to the forced polyambulatory closure during the COVID-19 pandemic. Exams strictly requiring in-person visit were performed at external centers nearby patient home.

Whenerver applicable, remote monitoring was activated for all device carriers (8) .

By 4-month initial experience, we applied our tele-MDU model to 144 patients. Full detail are reported in Table 1 . Of note, we reported no inpatients with SARS-CoV-2 genome in myocardium, and no opportunistic COVID-19 infections among outpatients on active immunosuppression. Also, there were compliance issues and no lost to follow-up.

Our research has multiple points worth highlighting: 1) to our knowledge, this is the first report about myocarditis management by multidisciplinary MDU; 2) thanks to the great coordinated efforts among the multiple operative units involved, the transition to tele-MDU was remarkably rapid; 3) to optimize hospital resources during a healthcare emergency, tele-MDU was primarly considered for inpatients, and subsequently translated to outpatients, offering a novel scenario for telemedicine application.

Although requiring further optimization, our model reflects the provision of care of a "home hospital", which was previously demonstrated effective in reducing cost, health care use, and readmissions, while improving patient experience (9,10). At this stage, constant patient-clinician engagement was maintained not only by platform, but also by email, telephone, video, and inperson reassessment, consistently with the hybrid models of care (11). The transition to tele-MDU was generally well-accepted by all the participants, also because of the young age of the participants. Challenges could be expected by extending our model to other settings, like elderly patients with chronic diseases and subjects with low socioeconomic status or limited access to technology (12). Figure 1 summarizes the main limitations of our model, as felt from both patient and physician viewpoints: ad-hoc questionnaires could be helpful to collect more accurate data. In

Journal Pre-proof our experience, the limited sample size allowed easy definition of priorities by in-person assessment of the MDU physicians: strategies for developing automated priority codes or creating direct connections with the polyambulatory agenda could be implemented in the future for a more fluid management of follow-up visits. Finally, because of the disease complexity and multidisciplinary expertise required, our model for myocarditis might be not easly reproduced outside tertiary centers.

We presented our multidisciplinary MDU and its rapid evolution to offer continuity of care to all our patients with previously-or newly-diagnosed myocarditis. Based on our expectations and preliminary findings, telemedicine is an effective way to follow-up patients suffering from a complex disease requiring constant multidisciplinary survelliance.

Of note, we felt that remote monitoring allowed to directly engage quarantined people in their homes; to actively promote communication between patients and their caregivers; to work out and communicate patient-tailored diagnostic and therapeutic strategies; and to monitor disease evolution.

In the current COVID-19 crisis, physicians are called to familiarize themselves with the technologies available at their own and other institutions, to guarantee the best remote care for their patients. Table 1 Results of a 4-month tele-MDU experience 

A novel coronavirus outbreak of global health concern

Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases

Hybrid FDG-PET/MR or FDG-PET/CT to Detect Disease Activity in Patients With Persisting Arrhythmias After Myocarditis

Clinical Presentation and Outcome in a Contemporary Cohort of Patients With Acute Myocarditis: Multicenter Lombardy Registry

Therapeutic strategies for virus-negative myocarditis: a comprehensive review

Arrhythmias in myocarditis: State of the art

Ventricular Arrhythmias in Myocarditis: Characterization and Relationships With Myocardial Inflammation

The COVID-19 challenge to cardiac electrophysiologists: optimizing resources at a referral center