Use of mechanical circulatory support guided by imaging modalities in treatment of influenza myocarditis: a case report

Introduction: Influenza affects millions worldwide every year. Although most cases are mild, severe complications can occur, including myocarditis1. Extracorporeal membrane oxygenation (ECMO) is a treatment option for patients with severe respiratory and/or cardiac failure. We present a case report of a patient with influenza-induced myocarditis and subsequent heart failure treated successfully with ECMO. Case report: 21-years-old male with no known history of medical illness presented to the Emergency Department at University Hospital Centre with fever, cough, and shortness of breath starting three weeks earlier. Chest X-ray showed pneumonia, PCR was COVID-19 negative but influenza positive. 12- lead electrocardiogram showed diffuse ST-segment elevation, cardiac biomarkers were elevated, and echocardiography verified reduced left ventricular ejection fraction (LVEF) of 44% with pericardial effusion. Patient was diagnosed with acute myopericarditis and pneumonia, admitted to hospital and started on broad-spectrum antibiotics. Four days later patient's respiratory distress worsened requiring intubation and mechanical ventilation. Hemodynamic status deteriorated requiring noradrenaline and dobutamine support. Bedside echocardiogram showed akinesia of inferolateral and anterolateral wall with severely reduced LVEF. Due to escalation of support and hemodynamic instability, decision was made to initiate veno-arterial (V-A) ECMO support. During the procedure patient had cardiac arrest and was successfully resuscitated two times. Two days later, patient was transported to University Hospital Centre Zagreb. Echocardiography showed LVEF of 20% while the chest X-ray showed signs of severe congestion interpreted as ECMO lung oedema. Due to that, an immediate implantation of Impella was performed. However, as soon as Impella established adequate cardiac output, a severe case of Harlequin syndrome developed which required conversion of ECMO configuration to V-A-V that stabilized the situation and enabled conversion into V-V ECMO two days later. Following further stabilization, VV ECMO was removed two days later, Impella the following day, and patient was extubated. Cardiac recuperation was dramatic and cardiac MRI showed an LVEF of 57%. Patient was discharged home after 24 days. Conclusion: This case highlights the appropriate use of different mechanical circulatory support modalities guided by different imaging modalities for bridging a case of severe influenza-induced myocarditis from a cardiac arrest situation to successful hospital discharge. [ FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

New fever and acute heart failure weeks after COVID-19 – red flags for multisystem inflammatory syndrome in adults

Introduction: A life-threatening hyperinflammatory condition occurring several weeks after primary infection with SARS-CoV-2 that can include severe acute heart failure has been reported in children in early 2020. Later on, a condition with similar characteristics has also been reported in adults.1,2 Case report: 26-year-old male patient with obesity and arterial hypertension presented to the emergency department with 3 days history of fever, chills, dyspnea, exercise intolerance, headache, dry cough, nasal discharge and diarrhea approximately six weeks after he has been diagnosed with mild COVID-19. Initial blood tests showed markedly elevated laboratory inflammatory markers. CT scan showed enlarged lymph nodes in the neck and small areas of residual ground-glass opacities in the lungs. Pulmonary thromboembolism was ruled out. He was admitted to the infectious disease clinic and was started on cloxacillin, ceftriaxone, antipyretics and appropriate rehydration. On the third day of hospital treatment, the patient complained of chest and neck pain and severe dyspnea. His general condition deteriorated rapidly, and he was transferred to the intensive care unit due to the development of cardiogenic shock. Inotropic and vasopressor support was initiated. Echocardiography showed mildly dilated left ventricle with severe impairment of global systolic function (LVEF 20 %). High-sensitivity troponin I and NT-proBNP were markedly elevated with a peak concentration of 792 and 18200 ng/l, respectively. Therefore, the patient was transferred to the tertiary center coronary care unit (CCU). Pulse steroid therapy and intravenous immunoglobulin were immediately initiated, while heart failure therapy was gradually introduced in the following days. Seven days after admission to CCU, multiparametric cardiac magnetic resonance imaging (MRI) revealed preserved LVEF with diffusely prolonged myocardial T1 relaxation time and T2 relaxation time, confirming myocardial injury and edema, respectively. There was no late gadolinium enhancement (Figure 1). Updated Lake-Louise criteria for myocarditis have been fulfilled.3 The following criteria for multisystem inflammatory syndrome in adults (MIS-A) were met: age over 21 years, a positive test result for previous SARS-CoV-2 infection, documented fever >38.0°C for ≥24 hours, laboratory evidence of inflammation, involvement of cardiovascular and gastrointestinal system, and severe illness requiring hospitalization. Conclusion: This case indicates that there is a vast diversity of clinical presentation and underlying mechanisms of COVID-19 and post-COVID-19 syndromes with myocardial injury. Recently described MIS-A is a rare but potentially life-threatening complication of previous SARS-CoV-2 infection. Clinicians should be aware of this syndrome in order to recognize it on time and start with appropriate treatment. [ABSTRACT FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cardiac arrest in COVID-19 myocarditis: a case report

Introduction: Coronavirus disease 2019 (COVID-19) was first described in China, in patients with flu-like symptoms in December 20191 . This family of viruses is known for its cardiotropism2. Arrhythmia is possible clinical manifestation in COVID-19 patients and several cases of COVID-19 myocarditis have been reported, some as a cause of death3. Case report: We present a case of a 37-years old, previously healthy, female patient who was admitted to COVID-19 Intensive care unit (ICU) at University Hospital Centre Zagreb after out of hospital cardiac arrest and successful resuscitation. She manifested episodes of chest pain and palpitations during two months prior to cardiac arrest. Initial laboratory findings showed elevated levels of high-sensitive troponin I and NT-proBNP, significant hypokalemia and normal values of C-reactive protein. Additional urgent work-up (pulmonary CT angiography and brain CT scan) showed no significant pathology and Sars-Cov-2 PCR RNA test came positive, without respiratory involvement. Due to ECG changes and ultrasound finding of reduced left ventricular ejection fraction (LVEF 25-30%) with anteroseptal and apical akinesia and inferior hypokinesia, urgent coronary angiography was performed, there were no signs of coronary artery disease, and the suspected diagnosis was Takotsubo cardiomyopathy or myocarditis. Soon after admission heart failure therapy was introduced, and follow-up echocardiography showed improvement in LVEF (40-45%). Patient was given no specific antiviral treatment nor corticosteroid therapy. Additional work-up regarding serology for cardiotropic viruses came negative, and IgG antibodies for Covid-19 showed borderline result. Cardiac magnetic resonance imaging (MRI) performed 18 days after initial event described recovered left ventricular ejection fraction (LVEF 53%), with mild hypokinesia, oedema and mid-wall late gadolinium enhancement in apical 2/3 of anterior, anteroseptal and anterolateral wall, with pattern characteristic for myocarditis (Figure 1)4. At follow-up, one month after discharge, patient is completely recovered, without signs of heart failure or arrhythmias, with preserved LVEF and normal NTproNBP levels. Conclusion: This case once again highlights cardiac complications of SARS-CoV-2 infection, without respiratory involvement. Also, it shows good prognosis without specific antiviral treatment, emphasizing importance of early introduction of heart failure therapy. [ABSTRACT FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)