ABSTRACT
The prevalence of heart failure in the population and the COVID pandemic have rendered increasingly necessary the integration of remote monitoring with cardiology teleconsultation. A patient with dilated cardimiopathy was subjected to ICD implantation (Boston Scientific Perciva DR) with remote monitoring (LatitudeTM). One month after implant, remote monitoring recorded an increase in the HeartLogicTM heart failure index, a decrease of right ventricular and atrial sensing, contextually to fluctuations of the impedance values of the two leads (Fig. 1). The patient reported having performed shoulder's rehabilitation therapy with probable manipulation of the ICD pocket. Chest X-ray showed dislocation of both leads with distal end of right atrial catheter in superior vena cava and distal end of right ventricular catheter in right atrium (Fig. 2A) and kinking of proximal segments (Fig. 2B), a picture compatible with diagnosis of Twiddler's syndrome. Implant revision confirmed lead kinking in the subcutaneous pocket (Fig. 3A). The atrial catheter, given the amount of tissue deposited at its distal end (Fig.3B) which prevented its active fixation, was replaced. Following discharge, an increase in the HeartLogicTM Heart Failure Index was detected. The outpatient visit showed the presence of pleural effusion and medical therapy was therefore optimized. In order to avoid frequent ambulatory visits to the patient, a cardiology teleconsultation was planned, which enabled to verify the clinical benefit of therapy's variation. Remote device monitoring confirmed HeartLogicTM Heart Failure Index normalization. In conclusion, the integration of remote monitoring with cardiology teleconsultation, enables to timely detect device malfunctions and prevent episodes of heart failure, avoiding further hospitalizations. This integration is even more useful and necessary in geographically disadvantaged areas, strengthening the link between the territory and the hospital, improving patients compliance and therapeutic adherence and thus allowing a progressive improvement of the symptoms and quality of life of heart failure patients.
ABSTRACT
Background. The clinical presentation of myocarditis is very variable, it can start as asymptomatic or it can manifest itself with acute and severe symptoms such as dyspnoea or chest pain. In rare cases, focal myocarditis can mimic acute myocardial infarction. Case report. We present the case of a 21-year-old man with no relevant medical history admitted at the emergency department (ED) of our hospital with severe chest pain spontaneously regressed after 20 minutes. There was no history of cocaine or other substance abuse, neither of chest wall trauma. The patient reported a gastrointestinal illness with diarrhea and fever two days before the initiation of the chest discomfort. At presentation, the patient was afebrile. His vital signs and ECG were normal. Blood analysis showed mildly increased levels of monocytes, Creactive protein, lactate dehydrogenase and high levels of troponin I (5274 pg/ml, cut off value 34,2 pg/ml). Transthoracic echocardiography revealed inferior wall motion abnormalities with preserved (57%) ejection fraction and without pericardial effusion. During evaluation in the ED the patient had another episode of acute chest pain, the ECG is shown in Figure 1. The patient underwent urgent coronary angiography, which showed normal epicardial coronary arteries. During the first hours of hospitalization in coronary intensive care unit, the patient had some episodes of intermittent chest pain with transient ST elevation and also some episodes of non sustained ventricular tachycardia;troponin I increased up to 15000 pg/ml. Nonsteroidal anti-inflammatory drugs and non-dihydropyridine calcium channel-blockers were initiated with gradual symptom improvement and laboratory findings. Cardiac magnetic resonance (CMR) showed inferolateral intramyocardial late gadolinium enhancement and oedema as for acute focal myocarditis (Figure 2). The serology for most common cardiotropic viruses was performed and COVID-19 nasopharyngeal swab was negative. During the rest of the hospitalization, the patient remained asymptomatic and troponin I decreased progressively. The patient was discharged after one week and enrolled in our follow-up program. After two weeks the patient was free of symptoms and ECG an TTE echo were improved. Conclusion. The correct diagnosis of myocardial diseases often requires integrated imaging. In this reported case, CMR led to the correct diagnosis of focal acute myocarditis.