Beyond the Infection: The Immunopathological Cascade and Novel Therapeutic Avenues in Viral Myocarditis.
Chen Yi Y, Liu Mengnan M, Wu Jinwen J, Li Yirui Y et al.
Viral myocarditis (VMC) is an inflammatory disease of the myocardium induced by infection with cardiotropic viruses. Its pathogenesis encompasses direct virus-induced myocardial injury and excessive host immune-mediated pathological responses. This review systematically delineates the dynamic progression of VMC, from viral invasion and immune activation to chronic myocardial remodeling. Special emphasis is placed on pattern recognition receptors (PRRs) in sensing viral components, and how mechanisms like cytokine storms, autoimmunity, and macrophage polarization imbalances drive myocardial injury and fibrosis. Furthermore, we summarize current and emerging therapeutic strategies-highlighting etiology-guided stratification based on myocardial viral genome status. For virus-positive cases, direct pathogen-targeted antivirals (e.g., interferon-beta [IFN-β], telbivudine), viral entry decoys, mitochondrial protectants, novel antiheart failure agents (SGLT2 inhibitors, ARNI), and blood component apheresis (TPE/IA) offer promising avenues. Conversely, immunosuppressive regimens, CAR-Treg therapies, and cytokine antagonists (e.g., IL-1β, TNF-α, IL-17) are strictly indicated for virus-negative inflammatory cardiomyopathy. The clinical translation potential and challenges in these multitarget interventions are discussed in detail. Despite advances in elucidating VMC immunopathology, precise management remains ch.allenging due to difficulties in balancing antiviral defense and inflammatory injury. Future research should leverage multiomics technologies and personalized multitarget approaches to improve clinical outcomes.