CMR report:
The CMR report revealed mildly enlarged LV size without LV hypertrophy
with moderately reduced LV systolic function LVEF =35% and thin and
aneurysmal LV apex –Normal RV size with mildly reduced RV function
(RVEF=42%).
LGE findings: In all inferolateral and septal segments, there was
widespread patchy subepicardial to mid wall fibrosis, as well as sub
endocardial fibrosis in the left ventricular apex.
Recent myocarditis possibly due to viral infection, as well as an
autoimmune or sarcoidosis disease, should be evaluated, according to CMR
tissue characterization criteria.
(Figure 1)
On the first visit in our clinic on January 2021, she complained of a
dyspnea on exertion, NYHA-FC II and a mild fatigue. Her vital signs were
stable with a blood pressure (BP) of 115/75 mmHg a heart rate (HR) of 90
beats per minute (bpm), she did not have fever and systemic oxygen
saturation was 96%.
Her physical examination was unremarkable except for bi-basilar fine
crackles. She did not have any skin lesions in terms of her LP. Her new
echocardiogram revealed no new changes compared to her last exam that
was mentioned earlier. On laboratory tests, there was no leukocytosis,
hemoglobin was 12.1 g/dl, the renal and liver function tests were within
normal limits and N terminal –pro natriuretic peptide (NT-pro BNP) was
885 pg/ml. The thyroid function test was within normal limits with a
higher than normal anti TPO.
The standard anti failure therapies was already started and the heart
failure (HF) guideline directed medical therapies with lisinopril,
bisoprolol, eplerenone, furosemide as well as levothyroxine were
continued for her. A few days later, her HF symptoms were aggravated and
she developed progressive dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, abdominal pain and nausea. She was admitted with the above
mentioned symptoms and rapidly progressed to a pre-shock state. She had
a BP of 85/60, an HR of 120 bpm, a distended jugular vein, bi basilar
lung crackles, hepatomegaly, mild ascites and 2+ pretibial pitting
edema. The creatinine was slightly increased (1.7-1.8 mg/dl). The
alanine aminotransferase (ALT), aspartate aminotransferase (AST) and
total bilirubin levels were 46 U/L,40 U/L,1.5 mg/dl, respectively,
NT-Pro BNP was more than 18000 pg/ml and cardiac troponin –I (CTnI) was
elevated. Her ECG showed a sinus tachycardia with low voltage QRSs and Q
wave in leads of I, III, aVF, V1-V6, ST segment elevations and T wave
inversions/flattening in V1-V6. (Figure 2)
New echocardiography showed mild LV enlargement with severe systolic
dysfunction, LVEF 15-20%, global hypokinesia and apical akinesia mild
RV enlargement with severe systolic dysfunction [Tricuspid annular
plane systolic excursion( TAPSE)=10 mm, RV peak systolic
myocardial velocity by tissue Doppler (RV Sm) =6 cm/sec], moderate to
severe mitral (MR) and tricuspid regurgitation(TR), a tricuspid
regurgitation gradient (TRG) of 25 mmHg and a plethoric inferior vena
cava (IVC) with an IVC size of 23 millimeter.
Considering her clinical condition, we had to start intravenous (IV)
inotrope and diuretic. After starting intravenous (IV) inotrope
(Milrinone) and furosemide infusion, she was scheduled for emergent
endomyocardial biopsy (EMBX) due to deterioration in hemodynamic and
clinical course. The right heart catheterization data at the time of
EMBX has been shown in table 1;
Table 1: Hemodynamic findings of patient