ABSTRACT
A 78-year-old woman presented twice with high sensitivity troponin I (hs-TnI) elevation. Two cardiac catheterizations showed nonocclusive coronary artery disease, and 2 cardiac magnetic resonance imaging scans were normal. With these investigations unable to explain the troponin I (hs-TnI) elevation, alternate troponin samples were sent to check for assay interference. Results from these troponin assays were low. With the patient having elevated rheumatoid factor as a potential contributor to assay interference, the lab reanalyzed the samples using heterophile antibody blocking tubes, revealing lower hs-TnI levels. This case serves as a reminder to consider assay interference when the clinical picture is inconsistent with ischemia.
Une femme de 78 ans a eu deux fois une hausse de la troponine I à haute sensibilité (TnI hs). Deux cathétérismes cardiaques ont montré une coronaropathie non obstructive, et deux examens d'imagerie cardiaque par résonance magnétique se sont révélés normaux. Devant l'incapacité de ces examens à expliquer la hausse de la troponine I (TnI hs), d'autres échantillons de troponine ont été envoyés pour vérifier les interférences sur le dosage. Les résultats de ces dosages de la troponine étaient faibles. Puisque la présence d'un facteur rhumatoïde élevé chez la patiente a possiblement contribué à l'interférence du dosage, le laboratoire a soumis l'échantillon à une nouvelle analyse au moyen de tubes bloquant les anticorps hétérophiles. Cette dernière analyse a mis en évidence des concentrations plus faibles de TnI hs. Ce cas rappelle de tenir compte de l'interférence du dosage lorsque le tableau clinique n'est pas compatible avec l'ischémie.
ABSTRACT
Immune checkpoint inhibitor therapy has been shown to improve outcomes across many types of malignancies. However, immune checkpoint inhibitor has been associated with several immune-related adverse events including myocarditis. We describe the case of a 69-year-old man with fulminant myocarditis likely due to pembrolizumab therapy, complicated by biventricular failure with cardiogenic shock. Because of deterioration in hemodynamic status refractory to conventional immunosuppression, therapeutic plasma exchange was performed, resulting in a rapid reduction of serum pembrolizumab levels, and marked clinical, radiological, and biochemical improvement. To our knowledge, this is the first reported case on the successful use of plasma exchange for pembrolizumab-associated fulminant myocarditis.
Il a été montré que le traitement par un inhibiteur du point de contrôle immunitaire améliore les résultats dans de nombreux types de cancer. Un inhibiteur du point de contrôle immunitaire a toutefois été associé à plusieurs effets indésirables d'origine immunologique, y compris la myocardite. Nous vous présentons le cas d'un homme de 69 ans ayant présenté une myocardite fulminante, probablement causée par un traitement par le pembrolizumab, compliquée par une insuffisance biventriculaire accompagnée d'un choc cardiogénique. En raison de la détérioration de l'état hémodynamique réfractaire à une immunosuppression classique, un échange plasmatique thérapeutique a été effectué, lequel a entraîné une réduction rapide des taux sériques de pembrolizumab, et une amélioration marquée sur les plans clinique, radiologique et biochimique. À notre connaissance, il s'agit du premier cas signalé dans lequel un échange plasmatique a été utilisé avec succès pour traiter une myocardite fulminante associée au pembrolizumab.
ABSTRACT
BACKGROUND: Our aim was to determine if end-stage liver disease (ESLD) is associated with an attenuated response to vasodilator-stress or dobutamine-stress using 82Rb-PET MPI with blood flow quantification. METHODS AND RESULTS: Pre-liver transplant patients who had a normal dipyridamole-stress (n = 27) or dobutamine-stress (n = 26) 82Rb PET/CT MPI study with no identifiable coronary artery calcium were identified retrospectively and compared to a prospectively identified low-risk of liver disease dipyridamole-stress control group (n = 20). The dipyridamole-stress liver disease group had a lower myocardial flow reserve (MFR) (1.89 ± 0.79) than the control group (2.79 ± 0.96, P < .05). The dobutamine-stress group had a higher MFR than both other groups (3.69 ± 1.49, P < .05). A moderate negative correlation between MELD score and MFR was demonstrated for the dipyridamole-stress liver disease group (r = - 0.473, P < .05). This correlation was not observed for the dobutamine-stress liver disease group (r = - 0.253, P = .21). The liver failure group as a whole (n = 53) had a higher resting myocardial blood flow (0.97 ± 0.33 mL/min/g) than the control group (0.82 ± 0.26, P < .05). CONCLUSION: Dipyridamole demonstrates an attenuated vasodilatory response in ESLD patients compared to a non-ESLD control group related to higher resting blood flow and comparatively reduced stress blood flow. Dobutamine does not demonstrate this effect implying it may be the preferred pharmacologic MPI stress agent for ESLD patients.
Subject(s)
Dobutamine , End Stage Liver Disease/diagnostic imaging , Liver Failure/diagnostic imaging , Myocardial Perfusion Imaging/methods , Positron Emission Tomography Computed Tomography/methods , Rubidium Radioisotopes , Vasodilation , Adult , Aged , Coronary Circulation/physiology , Dipyridamole , Female , Humans , Liver Failure/surgery , Liver Transplantation , Male , Middle Aged , Prospective Studies , Regression Analysis , Retrospective Studies , Severity of Illness Index , Vasodilator AgentsABSTRACT
Cardiac Magnetic Resonance Imaging has become a cornerstone in the evaluation of heart failure. It provides a comprehensive evaluation by answering all the pertinent clinical questions across the full pathological spectrum of heart failure. Nowadays, CMR is considered the gold standard in evaluation of ventricular volumes, wall motion and systolic function. Through its unique ability of tissue characterization, it provides incremental diagnostic and prognostic information and thus has emerged as a comprehensive imaging modality in heart failure. This review outlines the role of main conventional CMR sequences in the evaluation of heart failure and their impact in the management and prognosis.
