CONGRESS ABSTRACT

A 49-year-old male presented to our attention with epigastric pain and episodes of vomiting, accompanied by cold sweats and dyspnea that had started a few hours earlier. Upon arrival, the patient was hemodynamically unstable (systolic blood pressure was 80 mmHg) and the ECG showed a wide-complex tachycardia at rate of 230 bpm. Two DC shocks at 200 J were administered, restoring sinus rhythm. Antiarrhythmic therapy was initiated. The ETT revealed left ventricular dysfunction with a severely depressed ejection fraction (<30%) and global hypokinesia. Blood tests showed: Troponin 2.3 ng/ml, CRP 1.7 mg/dl and signs of acute liver failure. With the initial suspect of Acute Coronary Syndrome, coronary angiography was performed and demonstrated no significant coronary stenosis. The patient was admitted in our cardiac intensive care unit (ICU). Based on the anamnesis and clinical presentation, fulminant myocarditis was suspected. Due to persistent electrical instability, characterized by recurrent TV that required multiple electrical cardioversions, although maximal antiarrhythmic therapy, high dose of corticosteroid was promptly initiated with a clinical improvement. The patient was transferred to a referral center for advanced circulatory support. Once hemodynamic and electrical stability were restored, cardiac MRI was performed, revealing a basal inferior and lateral late gadolinium enhancement (LGE) band in the epicardial region, along with a focal area of edema in the lateral wall. This pattern allowed us to the final diagnosis: sub-acute myocarditis presented with an arrhythmic storm and cardiogenic shock. One week later, at the follow-up echocardiography, the patient showed normal left ventricular ejection fraction and normal segmental wall motion. DISCUSSION: Fulminant myocarditis is characterized by an unfavorable prognosis and a high risk of cardiac death, so rapid treatment with medical therapy was essential. Although good medical practice would require clinical and instrumental examinations to rule out an infectious cause, in our case it was the timely and massive use of high doses of cortisone that saved the patient’s life and give us time to take the patient to a referral center for advanced circulatory support. In fact, high doses of cortisone effectively attenuated the inflammatory injury to the myocardium, also reducing the development of arrhythmias.