Early recurrence of myocarditis with atrioventricular block while wearing a wearable cardioverter-defibrillator after fulminant myocarditis: A case report

Key Teaching Points•Repetitive or recurrent myocardial inflammation may occur after an obvious initial episode of myocarditis.•A wearable cardioverter-defibrillator (WCD) prevent sudden cardiac death (SCD) during the most vulnerable period diagnosis myocarditis. Aggressive use WCD be considered when risk SCD is especially high, such as in cases where ejection fraction has not fully returned there late gadolinium enhancement magnetic resonance.•If ventricular tachycardia fibrillation detected while wearing a WCD, can deliver shocks. However, arrest occurring recorded but treated. •Repetitive Myocarditis inflammatory disease myocardium that results from mononuclear cell infiltration and myocellular necrosis.1Fung G. Luo H. Qiu Y. Yang D. McManus B. Myocarditis. Circ Res. 2016; 118: 496-514Crossref PubMed Scopus (284) Google Scholar Fulminant myocarditis (FM) acute characterized by rapid severe decline function with high mortality rate. Different types arrhythmias, including complete atrioventricular (AV) block, (VT), (VF), (SCD), stage FM.2Kociol R.D. Cooper L.T. Fang J.C. et al.Recognition management fulminant myocarditis.Circulation. 2020; 141: e69-e92Crossref (245) Most patients FM require mechanical circulatory support to maintain end-organ perfusion until recovery.3Campochiaro C. Sartorelli S. Benedetti al.Arrhythmias myocarditis: state art.Heart Rhythm. 2019; 16: 793-801Abstract Full Text PDF (101) If survive phase crisis, they have improved favorable long-term survival rates, regardless whether used.4Maejima Yasu T. Kubo N. al.Long- term prognosis rescued percutaneous cardiopulmonary device.Circ J. 2004; 68: 829-833Crossref (31) some patients, lead irreversible damage prevents recovery left assist device heart transplant.2Kociol Moreover, repetitive been reported.5Kytö V. Sipilä Rautava P. Rate patient features associated recurrence myocarditis.Eur J Intern Med. 2014; 25: 946-950Abstract A myocarditis.6Tscholl Wielander Kelch F. al.Benefit cardioverter defibrillator for detection therapy arrhythmias myocarditis.ESC Heart Fail. 2021; 8: 2428-2437Crossref (6) Here, we report case early block standstill intermittently AV FM. 54-year-old man was asymptomatic noted electrocardiogram (ECG) abnormality (details unknown) physical examination 2 years ago. Echocardiography showed reduced (LVEF, 43%) enlarged end-diastolic dimension (LVDd, 67 mm). Multidetector computed tomography angiography revealed no abnormalities his coronary arteries, which raised suspicion dilated cardiomyopathy (DCM). Medical initiated. Two later, same presented emergency department exertion dyspnea. He prescribed any medication. His ECG sinus rhythm inversion T wave II, III, aVF (Figure 1A). Chest radiography enlargement pleural effusion, he diagnosed congestive failure. LVEF 27% LVDd mm. After started on medical therapies, diuretics beta-blockers, effusion decreased symptoms outpatient. One month attempting intensify medications, angiotensin-converting enzyme inhibitors, developed rapidly worsening dyspnea fever. On ECG, ST depression wide QRS V1–V6 were 1B), declined 15% (Supplemental Figure Emergency did show abnormality. The cardiogenic shock admission intubated. Intra-aortic balloon pumping venoarterial extracorporeal membrane oxygenation introduced. next day, sustained VT occurred, temporary pacemaker inserted, intra-aortic converted (Impella). An endomyocardial biopsy demonstrated numerous cells, indicating lymphocytic 2A). patient’s creatine kinase levels reached maximum 1678 U/L at 6 days admission. also treated prednisolone (1 g methylprednisolone per day 3 days) intravenous immunoglobulin (2 g/kg gradually improved, weaned off Impella 8 24, respectively. second biopsy, performed 22, decrease infiltrated cells interstitial fibrosis, suggesting had 2B). Dosages beta-blocker (7.5 mg carvedilol day), inhibitor perindopril mineralocorticoid receptor antagonist (25 spironolactone amiodarone (200 day) increased based tolerability, dobutamine 74. system removed, conduction restored, maintained, bradycardic event. At discharge, NYHA classification class brain natriuretic peptide (BNP) 71.0 pg/mL (target range <20 pg/mL); troponin I slightly elevated 0.022 ng/mL <0.014 ng/mL) 80.8 <26.2 pg/mL), respectively; C-reactive protein level 0.03 mg/dL <0.33 mg/dL), within normal range. before discharge rhythm, PQ interval 180 ms, duration 132 ms 1C). 35% 70 mm, respectively 1B). Cardiac resonance (CMR) imaging signal T2-weighted images basal septum (LGE) 2A 2C). discharged 87 months SCD.Figure 2Images biopsies. A: Myocardial interstitium. B: follow-up 22 fibrosis. C: 10 mild interstitium.View Large Image ViewerDownload Hi-res image Download (PPT) discharged, medication continued, 4 outpatient basis. condition worsen months, therapeutic shocks this period. 9 weeks hospital experienced dizziness loss consciousness, taken room ambulance. advanced (heart rate 35 beats/min), inserted immediately. When checked records approximately 20 seconds observed 3A 3B). Under pacing, (VVI 40) 62 beats/min complex (162 ms) V4–V6 1D). Laboratory testing level, white blood count (9020/μL), BNP 730.6 pg/mL. Creatine elevation (50 U/L), 0.193 1208.1 pg/mL, 29% mm Coronary significant stenosis interstitium CMR new clarified expanded LGE 2B 2D). These findings are consistent Therefore, administered immunoglobulin. these treatments, ST-T changes 1E). Finally, decided implant resynchronization (CRT-D) because (152 We continue immunomodulation following plan perform careful monitoring 1 year CRT-D implantation, biventricular pacing 98% 1F), echocardiography improvement 45% 56 31 pg/dL I, failure worsen. Furthermore, without arrhythmic events. encountered only 5 onset syncope, documented WCD. history prior asymptomatic; however, DCM suspected. judged event relapse onset, changes, levels, findings. Although paired serum antibody test significantly titer against virus, it highly likely virus involved. Pathogenically, toxin causes myocyte injury, immune stimulated, injures myocardium. In cases, viral clearance downregulation response follow, if infection controlled, ongoing injury leads DCM.7Cooper Jr., Myocarditis.N Engl 2009; 360: 1526-1538Crossref (962) Regarding differential diagnosis, sarcoidosis negative (no noncaseating epithelioid granuloma), serological tests enzyme, lysozyme, soluble interleukin receptor. course T2 short typical sarcoidosis. treatment external SCD. protect SCD, bridging decision implantable (ICD) implantation performed.8Piccini Sr., J.P. Allen L.A. Kudenchuk P.J. al.Wearable prevention death: science advisory American Association.Circulation. 133: 1715-1727Crossref passed, remained low, decreased, drug introduced first time; thus, further expected. yet consented ICD, option ICD re-evaluated removed. reported.6Tscholl Scholar,9Blaschke Lacour Dang P.L. cardioverter-defibrillator: friend foe suspected myocarditis?.ESC 2591-2596Crossref (2) save life. case, wore FM, discharge. To best our knowledge, caused recovered images.10Wu K.C. Sudden substrate imaged imaging: investigational tool clinical applications.Circ Cardiovasc Imaging. 2017; 10e005461Crossref (49) would high. case. time rare who This impacts WCDs future part diagnostic process.