It all starts with the ECG: cardiac MRI in combination with electrophysiological study to stratify arrhythmic risk in a patient with non-ischemic cardiomyopathy and preserved LVEF

Dan Ursu,Cristian Statescu,Laura Tapoi,Stefan Ailoaei,Mihaela Grecu,Alex Bostan,Radu Sascau,Carina-Gabriela Ureche,Anatolie Cazacu

doi:10.47803/rjc.2020.30.4.639

Abstract

A 45-year-old male, hypertensive and obese presented with a 3-months history of short episodes of intermittent palpitations. Clinical examination was unremarkable; however, the electrocardiogram documented major right bundle branch block and the presence of fragmented QRS in all precordial leads. His echocardiography documented a dilated left ventricle, with mild systolic dysfunction and moderate biventricular reduction of the global longitudinal strain. On angiography, the epicardial coronary arteries were normal. A cardiac MRI revealed diffuse transmural fi brotic lesions with non ischemic pattern of the ventricles, suggestive of chronic myocarditis. The electrophysiological study induced two ventricular tachycardia morphologies which were ablated and an ICD for sudden cardiac death primary prevention was implanted. Fortunately, at 6 months follow-up our patient had no ICD therapies and reported an alleviation of symptoms.

Highlights

A 45-year-old male, hypertensive and obese presented with a 3-months history of short episodes of intermittent palpitations
Lesions transmurality together with reduced strain values and high number of viable myocardial channels within the scar, suggested our patient was at high risk for sudden cardiac death (SCD) due to malignant ventricular arrhythmias, despite its preserved LVEF
At the end of the procedure the induction protocol was negative for monomorphic ventricular tachycardia, but ventricular fibrillation was still inducible, so an implantat un defibrilator cardiac (ICD) was implanted shortly after for the SCD primary prevention

Summary

PATIENT PRESENTATION

A 44-year-old gentleman, a sales agent, known hypertensive, obese and dyslipidemic presented with a 3-months history of fatigue and palpitations of abrupt onset and termination, a duration of up to 1 minute, accompanied by dyspnea. His home medication included Candesartan 8 mg OD and Atorvastatin 10 mg OD. The physical examination was within normal limits, with a blood pressure of 130/80 mmHg, regular heart rate of 92 bpm, SpO2 of 100% on room air and. The patient was a non-smoker with no history of drug abuse, previous heart surgery, recent invasive procedures or dental intervention

INITIAL WORK UP

DIAGNOSIS AND MANAGEMENT

FOLLOW-UP

CONCLUSIONS