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incapacitating and recurrence is inconsistent with Medical Assessment. The certification of aircrew
following pericarditis attributable to other pathologies will depend on the cause, completeness of
resolution, clinical stability and expected long-term outcome.
Constrictive pericarditis may follow a number of infections or may be idiopathic. Fatigue, breathlessness
and fluid retention are late clinical features, which, when evident, disbar from all forms of certification to
fly. Following pericardectomy, re-certification may be possible subject to essentially normal ventricular
function and demonstrated electrical stability. Such individuals however, commonly have a restrictive
myocardial defect and are likely to be unfit.
Myocarditis
1 Dressler’s syndrome: post-myocardial infarction syndrome. After William Dressler, Polish-American physician
(1890-1969).
ICAO Preliminary Unedited Version — October 2008 III-1-35
Acute viral myocarditis may merge seamlessly into dilated cardiomyopathy. Viral myocarditis is more
frequent than is diagnosed and may be present in one in 20 patients with a viraemia. Up to one-third of
patients with a recent diagnosis of dilated cardiomyopathy will have a past history of febrile illness
consistent with a myocarditis. In 1995 the WHO1 task force on the classification of the cardiomyopathies
introduced the “inflammatory cardiomyopathy” — DCMi. Characteristically, there is a systemic upset
which is associated with evidence of impaired ventricular function or heart failure and disturbance of
rhythm and/or conduction. Sudden cardiac death is also a feature. There may be an associated myalgia.
Most cases recover spontaneously, although the possibility of the development of late cardiomyopathy is
present. An MRI scan is likely to be helpful but myocardial biopsy may not be useful.
Viruses are not the only agents responsible for myocarditis. A large number of pathogens, metabolic
abnormalities, toxins and other causes have been described. The most common is ethanol (ethyl alcohol).
Acute alcoholic intoxication reduces myocardial function and predisposes to atrial and ventricular rhythm
disturbance, the most important of which is atrial fibrillation. Other toxins include carbon monoxide,
halogenated hydrocarbons, insect or snake bites, and cocaine. One cause of occult myocardial damage,
both acutely and long-term, is an anthracycline given in childhood for treatment of lymphoma and other
neoplastic conditions. There may be an initial myocarditis followed years later by the insidious
development of a cardiomyopathy. Unfortunately, the resting ECG is insensitive in the detection of the
subtle abnormalities of function in this group of patients who appear to have a potentially vulnerable
myocardium. Likewise, the echocardiogram may be unhelpful. An MRI will be more sensitive.
Following an episode of myocarditis, full investigation should include echocardiography, exercise ECG
and repeated 24-hour ambulatory monitoring to search for complex ventricular rhythm disturbances,
conduction disturbance and/or atrial fibrillation. The echocardiogram should have returned to normal
(i.e. have no evidence of impaired left or right ventricular function) and should be repeated in regular
follow-up. It is likely that an MRI scan will have been performed and contributed to the diagnosis. This
should include repeated Holter monitoring. Any evidence of increasing (left or right) ventricular internal
diameters and/or reduction of systolic (and/or diastolic) function is incompatible with certification.
Endocarditis
Endocarditis has an overall mortality of six per cent, although the presence of a virulent organism and/or
involvement of a prosthetic valve can elevate this up to ten-fold. Causes of death include sepsis, valve
failure giving rise to heart failure, and mycotic aneurysm. The acute illness disbars from all forms of
certification to fly. Treatment involves at least six weeks of antibiotic therapy, and recovery to full health
may take weeks longer, with a risk of relapse for several months. Once a patient has suffered an episode
of endocarditis, re-certification depends on good residual function of the heart as judged by standard noninvasive
techniques. The risk of re-infection with recurrence of endocarditis is increased. Such patients
require special antibiotic precautions with dental and urinary tract surgery.
Outcome is influenced favourably if renal and myocardial functions are normal after an attack and there
has been no systemic embolism. Involvement of the mitral or aortic valve, if it does not lead to significant
regurgitation, may leave a sterile vegetation that provides a nidus for cerebral embolism and re-infection.
There are several reports that post-discharge survival is reduced; for the above reasons, restricted
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Manual of Civil Aviation Medicine 1(95)
